Science and Research ForumBiosketch:

David Victor Power, MD, MPHDr. Power is a native of Dublin, Ireland, where he attended medical school and completed specialty training in family practice.

He received training as a sympto-thenTIal teacher with Anna Flynn, M.D., and served as the Chairperson of the Association ofNFP Teachers in Ireland, as well as a research officer for "Doctors for Life." In 1992. he moved to Omaha, Nebraska and

completed training as a NFP Practitioner and Medical Consultant through the Pope Paul VI Institute. He served on faculty atCreighton University in the Department of Family Medicine. In July of 1994. he moved to the University of Minnesota andearned a Master's in Public Health in Epidemiology. He has served on the Board of Directors of the North American PrimaryCare Research Group. He is currently Assistant Professor in Family Medicine at the University of Minnesota where he serves asAssistant Director of Medical Student Education in Family Medicine.

Abstract:

David V. Power.MD

Dept. of Family Practice and CommunityHealthBox 381 UMHC

Minneapolis, MN 55455

Understanding the effectiveness of Contraceptive andNatural Family Planning Methods.

Science has a responsibility to each individual and tosociety to measure the effectiveness of birth controlmethods as accurately and reliably as possible.

This paper is a review of the principles used toconsider the effectiveness of contraceptive methodsand of Natural Family Planning (NFP) methods.Several published articles were selected on the adviceof experts in this field. These articles were thensummarized and interpreted by this author. The resultis a paper that attempts to provide a comprehensiveand easily understood approach to the interpretationof contraceptive and NFP effectiveness studies. Thispaper is written for an audience that may notnecessarily possess skills in this area.

These are some key points addressed in this paper. Itis not possible to construct a perfect study to assesseffectiveness of any method of birth control, so everystudy 111this area will be flawed. The studypopulation needs to be precisely defined. Particularlyfor NFP analysis, it is important to know whetherstudy participation is restricted, for example. to non-learner. long- time users of the method. Life tableanalysis is now recognized as the best method toanalyze effectiveness and use of the Pearl formulashould be abandoned. A key issue, particularly forNFP analysis. is the definition of unintentionalpregnancy. User intention at the time of pregnancyoccurrence needs to be precisely identified. NFPeffectiveness studies appear superior to contraceptivestudies in their attention to this accurate definition. Ingeneral, contraceptive studies ignore this issue.

An important distinction between NFP and contraceptiveeffectiveness studies is that NFP studies invariably assess theuse of the NFP-using couple rather than the individual femaleuser of contraception. Many associated behavioral issuesmayconsequently be included in NFP analysis which are notconsidered in contraceptive studies. In calculating method anduse effectiveness statistics. it is clear that most studies ofcontraception and NFP are inaccurate. This is because ofimprecision in defining the 'at risk' populations for each statistic.Consequently, quoted method 'failure' statistics in the literaturefor most methods are incorrectly low.

A problem that is often encountered is difficulty incomparing NFP effectiveness with contraceptive methods.Gross, as opposed to net. life table statistics are mostsuitable for comparison between methods. It appears tothis author that the extended use effectiveness statisticmay be the most suitable means of comparing NFPeffectiveness with contraceptive methods. This is becausea change from use ofNFP to avoid pregnancy to its usewhere pregnancy may be achieved is a similar concept tothe abandonment of a contraceptive method. A pregnancythat results when an NFP user departs from the rulesnecessary to avoid pregnancy, but whose expressedintention is not to achieve pregnancy, may best berepresented within the extended use effectiveness statistic.Trussell, in analyzing one NFP study, has remarked thatNFP is 'extremely unforgiving of imperfect use'. Thisremark is considered further within this presentation.

52

Science and Research ForumBiosketch.

Lawrence E. Kay, MDDr. Kay graduated from Georgetown University Medical School and completed a Family Practice Residency at St.Margaret Memorial Hospital in Pittsburgh, Pennsylvania. He subsequently entered private practice of FamilyMedicine in Maryland. He subsequently became a faculty member at Polyclinic Family Practice Residency Programand in July of 1994 became Associate Program Director. He is a Clinical Assistant Professor of Family andCommunity Medicine at the Pennsylvania State University College of Medicine and at Temple University School ofMedicine. In June 1995, he published an article in post-graduate medicine entitled, "Adolescent Sexual Intercourse:Strategies for Promoting Abstinence in Teens". Dr. Kay is a Fellow of the American Academy of Family Physiciansand is a member of the Christian Medical Society and the Society of Teachers of Family Medicine.

Abstract:

Lawrence E. Kay, MDPolyclinic Medical Center

Family Practice Residency2601 N. 3rd Street

Harrisburg, PAl 7110

Adolescent Sexual Intercours~: Strategies to Promote Abstinence in Teens

Rev1ew of the medical and psychosocial adolescentliterature was accomplished through medline searches andsubsequent reference section searches over the past 20 (andup to 30 years for selected psychosocial references) withcollation and synthesis of this material to pursue thefollowing objectives: I) identification of the factorsinfluencing initiation of intercourse (in adolescents), 2)provision of a viable biopsychosocial framework for theintegration of these factors into primary care. 3) use of the"health promotion/disease prevention" model to approachadolescent sexual intercourse from a primary preventiveapproach (i.e., abstinence), 4) delineation of specificeducational strategies (aimed primarily at parents and caregivers and secondarily at the children and adolescentsthemselves) designed to promote abstinent behavior whichcan be implemented through well-child checkups by FamilyPractitioners or other Primary Care Providers. This studyresulted in the following findings: I) abundant literatureeXIsts documentmg what can be categorIzed as contributory

and protective factors influencing initiation of adolescentintercourse behavior. 2) the developmental literature supportsthe concept that sexual intercourse is a behavior which ispremature and developmentally inappropriate duringadolescence. 3) the academic medical literature has largelyignored (or dismissed) the concept that abstinence isapproachable or attainable as an interventive strategy, 4) a broadrange of educational interventions can be organized from theliterature reviewed which can realistically be expected topromote abstinent behavior in adolescents if widely utilized byprimary care physicians. Conclusions which are drawn fromthis study include: 1) abstinence (primary prevention) is anappropriate and desirable public health approach for primarycare providers to pursue in attempting to reduce theconsequences of adolescent sexual intercourse behavior, 2) theacademic hterature provides us with enough infomlation toformulate specific educational strategies aimed at parents and

, teens which can ultimately be expected to promote higher ratesof abstinent

53

Science and Research ForumBiosketch:

Joseph B. Stanford, MD, MSPH, CNFPMCDr. Stanford attended medical school at the University of Minnesota and completed a family practice residency and an academicfellowship at the University of Missouri-Columbia. He is Assistant Professor in the Department of Family and PreventiveMedicineat the University of Utah School of Medicine in Salt Lake City. He is active in research in a variety of dimensions ofNFP and currently serves as Chairperson of the Science and Research Committee of the AANFP.

Joseph B. Stanford, MD, MSPH, CNFPMCDepartment of Family and Preventive Medicine

50 No. Medical DriveSalt Lake City, UT 84132

Abstract:

Interest in Natural Family Planning among Couples in Utah

Background: A previous population based survey ofwomen in Missouri has shown that a substantial

percentage offertilc women (57%) were potentiallyinterested in using NFP. either to avoid or to achievepregnancy. There are no published data on men'sinterest in NFP.

Objective: This study was conducted 1) to corroboratethe Missouri study by determining which women in thestate of Utah would be interested in using NFP; 2) toassess the level of interest among their male partners.

Methods: A two-page (front and back) writtenquestionnaire used in the Missouri study was mailed to900 women, ages 18-50, who were randomly selectedfrom driver's license renewal records for the previousyear in the state of Utah. The questionnaire includedbasic demographic information, information aboutreproductive history and past use of all forms of familyplanning, mcluding NFP, reproductive intentions,attitudes towards possible future use ofNFP. and a briefexplanation ofNFP. A similar. slightly shorterquestionnaire was included for the women to give totheir husbands or male partners. where applicable.

Results:

WOMEN: After three mailings. 434 questionnaireswere returned (48%). Of respondents. 317 women(73%) had not undergone menopause or a sterilizingsurgIcal procedure and were still potentially fertile. Ofthese women. 65% indicated they would consider usingNFP under optimal circumstances; 29% indicated thatthey would be likely or very likely to use NFP in thefuture to avoid pregnancy, and 56% indicated that theywould be likely or very likely to use NFP in the futureto achieve pregnancy. Only 5% offertile women werecurrently using a method ofNFP.

MEN: Of the 434 women initially responding, 74%were married and an additional 7% were "single in acommitted relationship with a male partner," making353 women eligible to have male partners returnquestionnaires. Of these. 265 (75%) were returned. Ofthese men, 204 (77%) were both still potentially fertileand also had a potentially fertile wife or female partner.From this group, 63% indicated they would considerusing NFP under optimal circumstances; 40% indicatedthat they would be likely or very likely to use NFP inthe future to avoid pregnancy, and 59% indicated thatthey would be likely or very likely to use NFP in thefuture to achieve pregnancy.

Conclusions: Some women who are not currently usingNFP are interested in doing so in the

future. either to achieve or to avoid pregnancy. Inrelation to previous studies, this interest seems

to hold across women from a variety of demographicand religious backgrounds. Further, the

level of interest among their husbands or male partnersseems to be at least as high as among the

women themselves. These data have implications forthe availability ofNFP instruction, and for

physicians' attitudes towards NFP when discussingfamily planning options.

54

Science and Research ForumBiosketch:

Richard Fehring, DNSc, RN, CNFPEDr. Fehring received his Doctorate in Nursing Science from the Catholic University of America in 1981. He iscurrently Associate Professor of Nursing and Research Facilitator at Marquette University College of Nursing. He isthe coordinator and a practitioner in the NFP Clinic in St. Joseph's Hospital Center for Women and Infants inMilwaukee, Wisconsin. He is also past President of the American Academy of Natural Family Planning andcurrently serves as a member of the National Conference of Catholic Bishops NFP National Advisory Board. He haspublished widely in professional journals.

Abstract:

Richard Fehring, DNSc, RN, CNFPECollege of Nursing

Marquette UniversityMilwaukee, WI 53233

Accuracy of the Ovulon Fertility Monitor to predict and detect ovulation

BACKGROUND: The accurate prediction of ovulationis important for women who are trying to achieve or toavoid pregnancy. A promising new device called the'OVULON' fertility monitor (Conception Technology,Inc.) has been developed to help women determine thefertile period. The Ovulon has a vaginal sensor thatdetects biochemically stimulated changes in electricaladmittance. The monitor has three biological markers: along-term predictive peak about six days beforeovulation, a short term predictive peak about a daybefore ovulation. and another at the time of ovulation.

PURPOSE: The purpose of this study was to compareand correlate the peak in cervical mucus and the LHsurge in the urine with the three biological markers ofthe Ovulon fertility monitor.

METHODS: Ten volunteer female subjects (mean age30.2 years) with regular menstrual cycles (i.e., withcycles 21-38 days in length) who have been trained inthe usc ofthc ovulation method (mean months of use32.0) monitored their cervical-vaginal mucus, the surgeofLH in the urine with the OvuQuick assay test. andtheIr vaginal electrical readings (with the Ovulonmonitor) on a daily basis for one to four menstrualcycles using 10 prototype Ovulon monitors.

RESULTS: Nineteen of the 21 menstrual cyclesindicated a LH surge. In the 19 cycles with anestablished LH surge, there was a strong positivecorrelation between the LH surge in the urine and thePeak day of cervical mucus (r=0.96, p :::;0.0 I), betweenthe LH surge and the Ovulon nadir (r=0.84, p :::;0.0 I)and between the LH surge and the Ovulon short termpredictive peak (r=0.84, p:::;0.0 I). There was a modestpositive correlation between the long term Ovulonpredictive peak and the LH surge (r=0.62, p:::;0.01).There also was a strong positive correlation between thePeak day of cervical mucus and the Ovulon nadir(r=0.86, p :::;0.0 I). In the 19 cycles where a LH surgewas detected, the Ovulon short term predictive peak waswithin :f: 3 days of the surge.

CONCLUSION: The Ovulon has potential as anadjunctive device in the learning and use oftheovulation method of natural family planning. This isbecause the time of optimal fertility as determined bythe peak in cervical mucus and by the Ovulon monitorwas very similar. Both the peak in cervical mucus andthe Ovulon correlated closely with the LH surge.Although the LH surge is an accepted method ofdetenl1ining optimal time offertility, the use ofultrasound in tracking follicular development wouldhave been more accurate. Another limitation of the

study is that Ovulon data from 5 cycles was interpretedin light of the peak in cervical mucus rather than bystrict adherence to the established algorithm

55

Science and Research ForumBiosketch:

Mercedes Arzu Wilson,Mercedes Arzu Wilson is President and Founder of the Family of the Americas Foundation. She is a central pioneerin the field of natural family planning and assisted John and Evelyn Billings in some of their earliest work. Throughthe Family of the Americas, she continues to promote NFP throughout the world. She is the author of several booksincluding, "The Ovulation Method of Birth Regulation" and "Love and Fertility".

Abstract:

Mercedes Arzu Wilson, MDFamily of the Americas

P.O. Box 1170

Dunkirk, MD 20754-1170

Family of the Americas rides the wave of technology to educate theGeneration-X Crowd in Natural Famil~!!ning

The purpose of this paper is to introduce a series ofcomputer related products recently produced by theFamily of the Americas. An entirely new population ofNatural Family Planners has been created by theseprograms.

Charting Coach: The Family of the Americas hasrecently released the "Charting Coach" a computerprogram which "coaches" a couple as they chart theirdaily fertile symptoms of the Ovulation Method. Theprogram may be acquired as shareware on the Internet atour Web site (http://upbeat.com/family/om.html), andfrom aJi major online services including CompuServe.AOL Prodigy, and Eworld. We average 300 requestsfor the program over the Internet each month. As acouple uses the charting program, the computer helpsthem select the proper stamp, keeps track of theirentries, and provides them with the necessary guidelinesto avoid or achieve pregnancy. If a mistake is made. thecomputer corrects the couple, and re-explains to themthe rules ofthe Ovulation Method. The program doesnot just keep track of fertile symptoms, however. Thereis a section where daily comments or diary entries maybe kept. Entries may be printed in a daily calendar ormonthly calendar format and can be protected by apassword. The program is available for both Macintoshand Windows, and runs beautifully on Windows '95.

Nature's Method CD-ROM: In its ongoing effort toreach young families around the world. Family of theAmericas has developed a computer CD for bothMacintosh and Windows personal computers. Unlikethe "Charting Coach" which primarily coaches a couple

as they chart their fertile symptoms, the CD actuallyteaches the couple the Ovulation Method. The CD hasadapted the animation from the Love and Fertility videoto create interactive sequences that not only presentinformation, but also require the user to respond toquestions prompted throughout the presentation. TheCD also contains the full length "Love and Fertility"video, an abridged version of the FAF documentary, anda special section containing scientific information.

Internet: Family of the Americas opened its World WideWeb site in August '95 and has since received onaverage 2.000 visitors each month. We encourageeveryone to visit our new web site at(http://upbeat.com/family/om.html). The site isdesigned to introduce the millions of net surfers to theOvulation Method in a very straightforward, factualway. The site includes a table on the effectiveness ofthe Ovulation Method. Humanae Vitae translated fromthe Latin by Janet Smith. links to comments by MotherTheresa on NFP. and is the launch site of our newcharting computer program. the Charting Coach VUWe're planning to place the FAF catalogue on theInternet, make a page for people using the "lfY ou LoveMe. Show Me" CD-ROM, and possibly add someexcerpts from Mercedes Wilson's new book, Love andFamily.

Voice Recognition Technology: FAF in conjunctionwIth IBM and Apple Computer IScurrently developmga VOIcerecognitIOn verSIOnof the Charting CoachComputer program. Currently In development stages,the program may be released in late 1997.

56

Science and Research ForumBiosketch:

Francoise Pinguet, MDDr. Pinguet graduated from medical school in 197I and subsequently specialized in Obstetrics and Gynecology.Since] 98] she has been a staff member of the CLER Association, which works in natural family planning, familylife counseling and youth education. Since 1984 she has been responsible for NFP activity in that organizationincluding publishing out a NFP bu1letin and training NFP teachers. In 1989 she served as a consultant in naturalfamily planning for Georgetown Univcrsity for training trainers to teach NFP in French-speaking Africa. She hasalso provided NFP training In Santiago, Chile.

Abstract:

Francoise Pinguet, MD63-65 rue du Cherche-Midi

75006 ParisFRANCE

Effectiveness of NFP in French-speaking countries: an analysis of 626 users

The study presented here was conducted by sevenFrench-speaking organizations of Natural FamilyPlanning promotion, wanting to deepen their knowledgeof the practical aspect ofNFP cffectiveness between 1stOctober] 989 to 3 Ist January 1991. Participants had tosend a monthly self-observation chart with theirintention (to conceive or not) written down for the nextcycle and the next six months: the study planned tocollect 18 cycles per couple.

The analysis concerned 626 users ofNFP in order toavoid a conception during a total of 6740 cycles.Participation in the study did not interfere with theirplan of conception, and they were invited to behave asfar as possible, as though they ignored the study.Regarding socio-demographic characteristics, this studyconcerns young women, with a higher proportion ofmarried women and families of 3 or 4 children than the

French population. and with a lower proportion ofwomen with a job. 60% of the couples were classifiedas spacers indicating that the majority of the analyzedpopulation was not very firmly decided to avoid apregnancy: in the course of the study 41 .7% of thesample express the pian of conceiving in the next sixmonths.

Halfofthe population (47.7%) have used a method ofmtervention in the past. oral contraceptive. localcontraceptive or IUD.

A lot of them have already had experience of a year ormore of the use of natural family planning. A specialsub-group was analyzed: women following a previouspregnancy (22% of the population).

The onc-year pregnancy rate according to the actuarialmethod was I. I 3 for method failure, 6.47 for user +method failures, and 17.58 as overall pregnancy rate (92pregnancies). In 121 I cycles unions are limited to postovulatory phase: In none of them there occurred anyconception.

A Cox Model including pattern of sexual intercourseshows a greater risk in younger couples and post-partum. The couple's plan (spacers or limiters) is nolonger a risk factor when taking into account the patternof sexual intercourses in the analysis, showing that,probably, the effect ofthe motivation acts mainlythrough the pattern of sexual intercourse, and less or notthrough the quality ofthe self observation.

Indeed, effectiveness depends on the couple'smotivation and ability to cope with the situation ofabstinence during the fertile phase.

57

Science andBioskelch:

Research Forum

Sandro Girotto, MDDr. Girotto is a Family Physician in Verona, Italy. He is on staff at the Institute for Natural Fertility Regulation inVerona, Italy and in that capacity has been involved in the training of midwives to teach natural family planning inthe public sector in Italy. Dr. Girotto also participated as an invited observer in the meeting of the PontificalAcademy of Sciences regarding natural fertility regulation atthe Vatican in November of 1995.

Abstract:

Sandro Girotto, MDInstitute for Natural Fertility Regulation

Largo S. Nazaro1-37129 Verona

ITALY

An experience in the public sector in Italy:training of a group of midwives to teach NFP with two years' follow-up

In the social, cultural and scientific situation of thenineties. when our project has taken place. there areseveral new requirements for people involved in familyplanning (FP). These new requirements can besummarized as fo)]ows: J) The problem of humanfertility has biologicaL medicaL demographic,sociological, cultural and ethical implications. 2) Thechoice of family planning methods now fairly wellestablished with their implication for behavior. revealsome problematic and complex aspects. It is moreurgent to study a specific kind of advice that may suitthe different and alternative demands of people who aretired of contraceptive practice and its inability toprovide a permanent answer. 3) This type of advicewhich is "ad personam" or personal besides beingpeople's right, guarantees greater effectiveness in

fertility control as well as in preventing abortion. 4)The public service and public administrator must

consequently both obtain the necessary knowledge andmake a concerted effort to provide full information andsupport to people who seek this option of responsibleprocreation.

In this context we have planned a course for trainingmidwives working in the FP Clinics (ConsultoriFamiliari) of National Health Service of the EmiliaRomagna Region (Northern Italy). At the end of thecourse the midwives were able to: a)- present theapplication of the natural family planning (NFP)according to rigorous scientific criteria; b)- implementoperations under personal consultation; c)- characterizeand specifY the relative interactions to the application ofthe NFP with motivational and medical-sciencecomponents; d)- organize and manage a space inside thefamily planning clinics, health service institutions,hospital. etc. (NFP space).

At the end of the course they started the counselingwithin the "NFP space" in the FP clinics followed bythe supervision of the Institute RNF of Verona. Duringthe first two years 30 midwives advised 495 new usershaving the following characteristics: mean age 29. I8;the most were between 25-29 (32%) and 30-34 (27.9%);65.7% were married: 61.2% had school leavingcertificate 82.6% came ITom contraception: 63.5%chose NFP methods for medical and ecological reasonsand 40.8% came to NFP counseling for achievingpregnancy.

These last figures are well different from those coming

58