In Our Control (35 page)

It is frequently noted that FAM and the rhythm method are two different things. When people say this, they mean that calendar-based systems and those that rely on monitoring signs of fertility are discrete. I have found that terminology around different methods is very confusing. Some calendar-based systems, such as the Standard Days method, are referred to as subtypes of fertility awareness in some studies, but this isn’t accurate. The important thing to ask when analyzing a method of natural birth control is whether it depends on looking at a calendar, looking at what is going on in your body, or both.

Calendar-Based Methods

Q: What do you call people who use the rhythm method?
A: Parents
—Old Catholic school joke

The first category of natural birth control, under which the rhythm method falls, includes those systems that are calendar based. These methods rely on estimating when ovulation occurs based on either an average menstrual cycle or calculations made by observing an individual’s previous menstrual cycles. Couples practicing this type of birth control simply avoid sex during the days when it is believed that ovulation is occurring.

Calendar-based natural family planning systems are known to be significantly less effective than observational approaches, and the reasons for this should be obvious: if they are based on an average menstrual cycle—such as the classic twenty-eight-day model—they operate on the assumption that one woman’s body will work like another’s. If a method uses a women’s past cycles to guess when she is fertile, it assumes that she won’t experience any cycle variability over time. All women know that menstrual cycles are inconsistent, both among women and over the course of an individual woman’s life. Some women are different month to
month. One woman may have regular twenty-nine-day cycles, but her friend may experience a thirty-two-day cycle and then a twenty-five-day cycle. Even if a system is based on a woman’s own menstrual history, it is not necessarily accurate, because a number of factors (illness, stress, and travel, to name only a few) can cause even the most regular among us to have an atypical month.

Advocates of calendar-based systems argue that they are simpler to learn and less difficult to practice than other methods. This sort of assumption is based on the belief that women are too lazy to take their temperature every day, as well as other ideas about the abilities of uneducated women to fulfill and understand the tasks involved in using a technique that involves observation of fertility signs.

The problem with this sort of approach—and its implicit assumptions—can be seen in a 1999 study involving teaching fertility awareness to Mayan women. In designing the study, researchers working with the Population Council wrote:

More than half of Mayan women have never attended school. Given such low educational levels, the ease with which a method can be learned could affect both adoption of the method and its effectiveness. A blanket calendar method with simple rules of abstinence that are applicable to all couples would appear to offer advantages in its simplicity over other natural methods that require observations of cervical mucus or basal body temperature.
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Researchers admitted, however, that the workability of their plan would depend on the women they were instructing having, on the whole, regular menstrual cycles. They were basically saying that something was better than nothing.

What they found, of course, was that even women who claimed to have regular cycles often had striking inconsistencies when compared with other women and individually from month to month. Researchers concluded that because their cycles “may not be very regular,” a calendar method—in this case the Necklace system—might put women at “an unacceptable risk of pregnancy.”
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Again, the problem here is the assumption that there is such a thing as a regular menstrual cycle. Indeed, the only thing that seems regular is variability. The misconception among women and health care professionals that most women bleed every twenty-eight to thirty-one days is responsible not only for countless unplanned pregnancies, but also for the unnecessary medicating, often with oral contraceptives, of women for menstrual irregularities.

Still, new systems based on this relatively old way of performing natural family planning continue to be developed. The Necklace method, which involves using beads to count supposedly fertile and unfertile days, is a variant on the Standard Days method, which relies on creating a fixed system of days during which couples abstain (or use alternate contraception).

The Standard Days/Necklace method was developed and tested in the 1990s by researchers at the Institute for Reproductive Health (IRH) of Georgetown University (a Catholic university). Standard Days
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was developed, in part, in response to a belief that it would be too difficult to educate populations—particularly international populations—about more precise but complicated natural contraceptive techniques.
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Victoria Jennings, one of the researchers who tested Standard Days, notes, “These methods are just too complicated … It takes two weeks to train a provider on these methods at minimum, and eight sessions with a client to learn how to use these methods.”
¹¹

In studies published in the journal
Contraception
in 2002 and 2004, Standard Days was studied in populations of women in Bolivia, Peru, and the Philippines. Women were given a CycleBeads necklace and followed for thirteen cycles. Study authors announced proudly that only 43 of their 478 participants became pregnant (around 12 percent), an efficacy “comparable to that of male condoms” and “significantly better than that of other barrier methods (female condom, diaphragm, cervical cap, or spermicides).”
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It is important to note that only women with regular menstrual cycles—between twenty-six and thirty-two days—were included in the study.
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This was all quite exciting, and Georgetown wasted no time in marketing CycleBeads to the general public. The necklace is composed of thirty-two plastic beads: nineteen coffee-colored beads, split by twelve glow-in-the-dark white beads, and one tomato red bead. At the center of
the string sits a black cylinder with a shiftable black ring. On the first day of a woman’s period, she moves the black ring to the red bead. Each day she moves it ahead one bead, first over the initial set of brown beads, then onto the white ones, and eventually back to brown. When a woman hits the white beads, she considers herself fertile and either abstains for twelve days or uses alternative contraception (this choice is a touchy issue for natural family planners, who are still, on the whole, religiously motivated and opposed to barrier contraception). By July 2004, the IRH estimated that thirty thousand women had started using the method.
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I asked Toni Weschler, author of the most influential FAM guidebook around—
Taking Charge of Your Fertility
—about CycleBeads. Weschler is warm and patient, but she didn’t hesitate to offer her opinion:

As far as menstrual beads, don’t get me started!
Awful
. For one thing, they are no different than the rhythm method, since they don’t account for potential variation in the day of ovulation! And they are only effective for women with consistent twenty-six to thirty-two-day cycles. They tell all these women that they are fertile between days 8 through 19, regardless of what their unique cycle might be any given month. Which begs the question, why should they even use the silly beads at all. Why not just make a blanket statement that if you have cycles between days 26 and 32 days, consider yourself fertile between days 8 and 19, and don’t waste your time with the beads? Also, in any given month, the woman could ovulate much earlier or later than normal, and bingo—an unplanned pregnancy!
¹⁵

Feminist women’s health centers offer an alternative calendar method based on a woman’s individual cycle history. To practice this method, a woman records her cycles for eight to twelve months, noting their length and the number of days of bleeding in each. After this time, a woman can subtract eighteen from the length of her shortest cycle, noting this as the first fertile day. She can then subtract eleven from the length of her longest cycle, noting this as her last fertile day. So if the shortest period is twenty-seven days (27 – 18 = 9) and the longest period is thirty-one days (31 – 11 =20),
a woman can estimate that her first fertile day is the ninth day of her cycle (with the first day of bleeding serving as day one) and her last fertile day is the twentieth day. She would then need either to abstain from sex or use alternative contraception for twelve days.
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Because women’s cycles change throughout their lives, this number should be recalculated each month, adding the most recent cycle’s information. As noted above, however, the fact that even a woman with very regular periods experiences periodic variations casts serious doubt on this sort of system.

Monitoring Fertility Signs

In the 1930s, when John Smulders, a Dutch physician, and other doctors were settling on a formula for the rhythm method, Father Wilhelm Hillebrand, a Catholic priest, was working on a system to curtail pregnancy by monitoring basal body temperature (a woman’s waking temperature after at least six hours of sleep). As fertility expert Katie Singer notes, “Before ovulation, your body is cooler. After ovulation, your temperature will warm up and stay warm.”
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This rise in body heat happens because of progesterone, the hormone released by the ovarian follicle once an egg has burst forth and the follicle has retreated to corpus luteum status. By monitoring and recording daily temperatures, women can tell with some accuracy if ovulation has taken place.

In the early 1950s, Dr. John Billings, an Australian doctor and father of nine, pioneered a method of fertility control based on watching changes in cervical fluid (sometimes called cervical mucus), substances produced by the cervix that can aid or impede the ability of sperm to survive. The cervical fluids respond to hormones during the menstrual cycle, and in the days before ovulation, become sticky and stretchy, like an egg white. Once ovulation has passed, the cervical fluids become creamy, pasty, or they dry up completely. Significantly, while Billings first advocated both temperature and fluid methods, he eventually decided this combined system was too complicated and decided instead to encourage only fluid monitoring.

Today, a modern day version of the fluid-only approach is the TwoDay method
¹⁸
of fertility control. Another product of Georgetown’s IRH, this
technique councils women to ask themselves two questions each day. The first is “Did I note any secretions today?” and the second is “Did I note any secretions yesterday?”
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Researchers studying the method explain, “If she noticed no cervical secretions of any type today or yesterday, her probability of getting pregnant from intercourse today is very low.”
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To test this system, trial authors observed 450 women in Guatemala, Peru, and the Philippines. Of the 52.7 percent of women who completed the trial, forty-seven got pregnant. This method makes many assumptions, among them that women can differentiate cervical secretions from other kinds of vaginal discharge (such as fluids having to do with sexual arousal) without other types of information. One senses, reading the literature, that Georgetown isn’t entirely happy with this method; even in a study supporting TwoDay’s efficacy, they promote Standard Days. Still, they note, the advantage of the TwoDay method is that women with longer and shorter than normal cycles can use it as well.

By the 1970s, Catholic groups had started to teach methods that combined temperature recording with observation of cervical fluid and cervical position (which changes, like fluid, in response to hormones throughout the menstrual cycle). These approaches, called “symptothermal” methods, became the basis for FAM, the type of natural birth control that has been shown to be by far the most efficacious.

In the decades before the 1970s, most resources regarding natural contraception came from and were administered by the Catholic Church. Katie Singer explains that this often caused problems because it limited access to classes and information to those whose relationships and sexual practices fell within Church-approved models.

By the time Singer was learning about the method years later, things hadn’t changed very much. She describes her introduction to fertility awareness, which came after years of struggling with contraception she didn’t like and persistent yeast infections: “I began learning fertility awareness primarily by taking classes and reading literature put out by Catholic organizations. Many statements in the literature didn’t suit me. Despite my discomfort, I started to observe and record my fertility signals.”
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In 1997, after developing an enthusiasm for the method, Singer tried to take a class with a local expert in New Mexico, where she lived. The woman told her politely that she could give Singer an application for the class,
but couldn’t accept her because she was unmarried and had “genital contact.”
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Singer went on to write a lovely, comprehensive book on FAM called
The Garden of Fertility
and to counsel women both on the method and on other important aspects of health—such as nutrition—that can profoundly impact menstruation and conception.