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
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
The "in house debate" begins when different provider
groups put different emphases on the components of Natural Family
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.
The public sector, in the meantime, changed the terminology for
pregnancy from method or user failure pregnancies to:
- Method Related Pregnancy - The method was used correctly and
consistently but the woman conceived.
- Informed Choice Pregnancy - The Couple understood their
fertility, had intended to avoid pregnancy, but had intercourse during
the time of recognized fertility.
- Teaching Related Pregnancy - There was misunderstanding of the
method, due either to the user or to the teacher.
Unresolved - Insufficient information to categorize the
1) "perfect use" --
pregnacy resulting from the limitation of the correctly used method
"imperfect or typical use" - How the method is applied
in everyday use.
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
The Trussell and Kost computation separates perfect use from
typical use cycles and calculates rates separately.
Using any computation, "perfect use" pregnancies with Natural
Family Planning are very low, ranging from 0-2.8%
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
But motivation, intent and behavior are distinct.
As Kambic says
"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,
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
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
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.
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?"
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
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 
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.
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
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?
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
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
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
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
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.
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.
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
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