A Pilot Study on teaching Natural Family Planning in general practice

Dr Elizabeth Clubb, Dr Cecilia Pyper and Jane Knight

presented at Washington Conference on
‘Natural Family Planning:
Current Knowledge and New Strategies for the 1990s‘



This study examines the feasibility of teaching natural family planning in a general medical practice.


Results showed high rates of use effectiveness and relatively low cost.

Additional benefits are helping couples with difficulty conceiving to achieve pregnancy and assisting young women to understand their own sexual development better.


In the Oxford area, natural family planning (NFP) was being taught by trained teachers in a voluntary organisation.

The demand for this service was increasing and could not be met by the teachers available.

To determine how best to meet this demand, a study was conducted to assess

  • the feasibility of teaching NFP in general practice;
  • the efficiency of the symptothermal method (STM) as taught in general practice;
  • the time taken to instruct each patient;
  • the cost of giving this service to each patient;
  • the value of teaching NFP in groups using audio-visual programs; and
  • the educational value of teaching women to understand their own fertility.

Methods

In this community-based study, NFP instruction was given to clients by a practice nurse supported by two doctors.

An initial interest session was arranged for small groups of women or couples.

Couples were encouraged to attend, but the majority of women came without their partners.

The study participants, that is, those women who wished to learn a

natural method, were offered five educational sessions at monthly intervals.


The participants were taught fertility awareness by the symptothermal method (1), which combines the daily observation of the cervical mucus symptom with the recording of the basal body temperature.

Those couples wishing to avoid pregnancy were advised to have sexual intercourse during the infertile phases of the cycle and to abstain from intercourse during the fertile phase; but couples wishing to use barrier contraception during this time were free to do so.


Couples wishing to achieve pregnancy were taught fertility awareness, aiming to identify the days of maximum fertility.

The teaching time was recorded to evaluate the time taken for each woman to reach autonomy (according to the criteria of the programme) and hence the cost of teaching natural methods in general practice.


Group teaching and audio-visual programmes

Group teaching and audio-visual programmes were used to reduce the time taken to teach each client, thereby reducing the cost per client.

The women received instruction in small groups.

Every effort was made to form groups of women / couples of similar age and educational background, and also according to their fertility status (for example, women of normal fertility avoiding pregnancy, breast feeding mothers, and women during the pre-menopause).

Women with problems of infertility were seen individually, preferably with their partners.


The audio-visual programme on NFP, which explains the scientific basis for natural methods and describes the symptothermal method in detail, was shown to all women at the first session. Other programmes for women during lactation and for women in the premenopause age group were shown as appropriate.

All interested women were accepted, irrespective of age or state of fertility.

Of 208 accepted women, 102 completed fertility charts for one cycle and expressed a wish to continue charting.

(Of the remaining 106, 64 were interested only in learning fertility awareness, and 42 attended only the initial sessions).

The 102 participants formed the main study sample and were asked to provide at least twelve fertility charts for the purpose of the study.


The majority of women expressed a need to avoid pregnancy when they entered the study; the remainder were actively planning pregnancy.

Of the four women with other reasons for charting their cycles, three had suffered from disturbing symptoms thought to be pre-menstrual, and one woman had suffered chronic ill-health with bouts of pyrexia.

These women were not using their knowledge of fertility awareness as a family planning method, but information on their charts helped to diagnose the cause of their symptoms.


The majority of women in this study chose to use natural methods for reasons of ecological preference or for moral reasons.

Many of the women, a number of whom were looking for an alternative method because of medical advice, had previously used other methods of contraception.



Results

During the two-year study period, 903 charts were kept by women avoiding pregnancy.

There were two failures, one a method failure and one a user failure.

Thus, pregnancy rates were 2.7, calculated with the Pearl Index.

No pregnancies resulted from couples who at times used barrier methods of contraception during the fertile time.

Of the twenty-six women who wanted to become pregnant, nineteen succeeded during the two years.

The majority of these women learned to identify the fertile phase of the cycle by recognition of the cervical mucus symptom and became pregnant within three to four months.

Two women who had recently stopped using hormonal contraception took eleven and fourteen months before normal cycles were charted and pregnancies were achieved. Seven women were attending the fertility clinic.


Three conceived following education about how to identify the most fertile days, although the cause of their infertility was never found.

Increasing awareness of the fertile time allowed more accurate timing of intercourse, particularly valuable for two of the women who had very long and irregular cycles and were thought to have had a history of miscarriage.


Three women conceived while taking fertility drugs. Two were on clomiphene and one on bromocriptine. These women felt their increased understanding of fertility had played some part in helping them to time intercourse to achieve pregnancy.

One thirty-nine year old, who discontinued her course of fertility drugs on consultant advice, conceived several months later using her knowledge of fertility awareness.


The cost of teaching NFP in general practice was calculated. (See Tables I & II)

During this study, two general practitioners acted as medical advisors when problems arose, but were not involved in the routine teaching of the method.

In costing other methods of family planning, the general practitioners' fees and the practice nurse's salary were included with the cost of pills or devices.


The cost of teaching NFP in general practice, whether to women of normal fertility or to women in special circumstances, compares favourably with other methods over a two-year period even though there are high costs during the first year.


Women of normal fertility took less time to teach than those in 'special circumstances',
ie. lactating women, pre-menopausal women, and women experiencing delayed return of normal fertility following the use of oral contraceptives.

The average teaching time per client for women avoiding pregnancy was four hours.

 

Cost per client (as at 1990) for one year of NFP use
Family planning nurse's salary (4 hours)17.60
Cost of thermometer3.50
Cost of charts / year1.20
Total first-year cost 22.30
Table I



 

Projected cost per client over ten years
(as at 1990) for Family Planning in U.K.
All Family Planning Methods
Contraceptive pills234.50
Barrier methods255.50
Intrauterine devices260.40
Injectable contraceptives213.00
Natural methods52.40
Analysis of NFP costs
First year22.30
Extra teaching (2 hours)8.80
Thermometers10.50
Charts (9 years)10.80
TOTAL52.40
Table II



Discussion

NFP should be offered by family planning clinics and by general practitioners who give a family planning service as an alternative to artificial methods of contraception.


This small study taught the symptothermal method and produced an overall efficacy rate of 2.7 on the Pearl Index.

This rate is comparable to the intrauterine device (IUD) (1-5) or barrier methods (3-6).

Only the combined pill and injectables (less than 1) and the progestogen-only pill (1-2) are more efficient reversible methods (2).

The majority of the women in the study chose a non-invasive method of family planning, frequently citing unwanted side effects as reasons for turning away from artificial methods.


There are other positive aspects to giving education in fertility.


For example, in England, where one couple in eight has a fertility problem, education was all that was needed to achieve pregnancy in the majority of cases in this study.

Education in fertility awareness was appreciated by women who wanted this information but did not plan to use NFP immediately.

From the questionnaires, it emerged that the women were helped to understand their developing sexuality, physically and emotionally.

They felt better prepared to make responsible decisions about relationships and their choice of a method of family planning.


In this two-year pilot study on teaching NFP in general practice, it has been shown that the STM can be an efficient and cost-effective method of family planning.




Natural methods of family planning.
J.R.S.H. 1986; 106:4:121-6
References
  1. Roetzer, J. Sympto-thermal methods of natural family planning.
International Review of Family Planning 1981; 5:200-2
  2. Clubb, E.
3. France, J. The detection of ovulation for fertility and infertility.
Recent Advances in Obstetrics and Gynaecology
Ed J. Bonnar Churchill & Livingstone pp. 215-39 1983
4. Depares J,
Ryder R,
Norman C.
Ovarian ultra-sonography highlights precison of symptoms
of ovulation as markers of ovulation.
BMJ 292, 1562 14 June 1986.
5. Marshall J. Mucus and basal body temperature method of regulating births.
Field trial. Lancet 1976 Vol 2 pp 282-283.
6. Loudon N. Edit, Handbook of Contraception Churchill & Livingstone 1985



The Authors wish to thank
Dr Michael Woolridge of the Department of Child Health at Bristol Maternity Hospital
for his help in planning this study.
Dr Laurence Villard, the Department of Community Medicine and General Practice, Oxford,
for his help in preparing this paper.
Professor John Bonnar of Trinity College, Dublin, for his help in preparing this paper.
The Family Research Trust who provided the financial support which made this research project possible.
The Royal College of General Practitioners,
who provided the financial support which made this research project possible.



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