Title: Types of natural family planning
Course: Level 3 - Family Planning > Section: Natural family planning methods

There are three major classifications of natural family planning methods:

- Periodic abstinence (fertility awareness) method.
- Use of breastfeeding or lactational amenorrhea method (LAM)
- Coitus interrupts (withdrawal or pulling out) method.

Periodic Abstinence (Fertility Awareness) Methods

"Fertility awareness" means that a woman knows how to tell when the fertile time of her menstrual cycle starts and ends. (The fertile time is when she can become pregnant. In the menstrual cycle, the female hormones oestrogen and progesterone cause some observable effects and symptoms Estrogen produces a change in the cervical mucus, from thick, opaque and sticky to thin, transparent and slippery as ovulation approaches. Progesterone provides a slight rise in basal body temperature (temperature at rest) after ovulation.

Progesterone produces a small increase in basal body temperature after ovulation. The function of progesterone on the cervical mucus is just the opposite effect of oestrogen. It makes the cervical mucus thick, opaque and sticky. These changes provide the basis for the periodic abstinence methods

The fertility awareness methods are divided into three broad categories:

1. Calendar-based (rhytm) method
2. Cervical mucus
3. Basal body temperature method (BBT)

1. Calendar Based (Rhythm) Method

The Calendar based (rhythm) method is a method by which a woman calculates the fertile days of her menstrual period and the couple avoids vaginal sex, or uses temporary methods during the fertile time. It is based on the regularity of the menstrual cycle and the fact that an ovum (egg) can only be fertilised within 24 hours of ovulation (Figure 4.1).

What do you know about the regular and irregular menstrual cycle of a woman?:

- A regular menstrual cycle is when monthly bleeding happens every 28 days.
- An irregular menstrual cycle is when monthly bleeding is variable from month to month, for example, it can vary from 25 to 32 days in some women.

Before relying on rhythm method, a woman records the number of days in each menstrual cycle for at least six months. The first day of monthly bleeding is always counted as day 1. The woman subtracts 18 from the length of her shortest recorded cycle. This number tells her the estimated first day of her fertile time. Then, she subtracts 11 days from the length of her longest recorded period. This shows her the expected last day of her fertile time.

Example 1:
A woman's last six menstrual cycles were 28, 29, 29, 27, 31 and 27 days. Using this information, calculate and instruct her about how to use the calendar method to prevent pregnancy. The shortest of her last six cycles was 27 days, 27 - 18 = 9. She starts avoiding unprotected sex on day 9. The longest of her last six cycles was 31 days, 31 - 11 = 20. She can have unprotected sex again on day 21. Thus, she must avoid unprotected sex from day 9 through day 20 of her cycle.

However, if the client's menstrual cycle is regular and comes every 28 days or close to it, ovulation should occur about 14 days before the next period. For this reason, the woman should count backwards 14 days from her next period to calculate the day she will ovulate. Consequently, she should avoid sex from about seven days before that day until about two days after ovulation is expected.

Fig.4.1. White beads days are days when she can get pregnant and brown bead days are days when pregnancy is unlikely.

Example 2:
A client comes to you and asks about using the calendar method to prevent Pregnancy. When you ask her about the history of her menstrual cycle over the last six months, she tells you it regularly comes every 29 days. Calculate the fertile period of your client and advise her when to avoid sex to prevent pregnancy.

Answer:
Regular cycle 29 - 14 = 15
First day of fertile phase 15 - 7 = 8
Last day of fertile phase 15 + 2 = 17
Therefore, her fertile period is between the 8th and 17th days, and she should avoid sex between these days of the cycle.

Advantages of the calendar (rhytm) method:

- Greater involvement of partner to avoid pregnancy.
- No prescription needed.
- Increased communication between the couple.
- Increased awareness on how to become pregnant if conception is desired.

Disadvantages of the calendar (rhytm) method:

- High failure rate if not used consistently and correctly.
- Fewer "safe" days to have intercourse each month.
- Training is essential.
- No protection from STIs.
- If periods are not regular, may not be as effective.

Effectiveness of the calendar (rhytm) method:

With consistent and correct use, about five pregnancies per 100 women in the first year of use will occur. This data means more than 95 women will avoid potential unplanned pregnancy in the first year of use.

- What can a couple do if they are fear about using this method?.
- Advised them to use additional methods, like condoms or other barrier methods, to prevent unwanted pregnancy. You should provide them with the necessary resources.

2. Basal Body Temperature Method

The Basal body temperature method is a symptom-based method that relies on the woman's ability to notice a slight increase in her body temperature. The elevation in the temperature is as a result of hormonal changes that lead to ovulation (Figure 4.2).

The woman takes her body temperature at the same time each morning before she gets out of bed and before she eats anything. She records her temperature on an individual graph.

Her temperature will rise slightly-0.3° to 0.5° C just after ovulation (usually about midway through the menstrual cycle). The increase in body temperature sustained for three consecutive days indicates that ovulation has occurred, and it remains at this increased level until the start of the next menstrual cycle. In this section you will learn about when the rise in body temperature occurs, and what women need to know to use this method correctly. It is challenging to use natural family planning method if the woman's menstrual cycle is irregular, as it may disturb the subtle changes in body temperature and cervical secretions, as a result of hormonal effects.

Figure 4.2 An example of basal body temperature variations during a menstrual cycle. Note that the pattern varies in different women.

Advantages:

- Increased communication between couple.
- Increased awareness on how to become pregnant if conception is desired.

Disadvantages:

- High failure rate if not used consistently and correctly.
- No protection from STIs.
- Training is essential.
- False interpretation or indications in the case of fever, as this may mislead the result of BBT.
- A special thermometer may be required.

Effectiveness:

With consistent and correct use, one pregnancy per 100 women using BBT method will get pregnant in the first year. So., 99 of every 100 women relying on BBT method will not become pregnant. Its effectiveness will decrease dramatically to 80% if the woman does not use the method correctly. Effectiveness is greatest when the couple limits unprotected sexual intercourse to the period after ovulation.

Key points to remember:

- Watch for a slight rise in temperature at about midway between the menstrual cycles.
- Avoid unprotected vaginal sex from the first day of monthly bleeding until three days after the woman's temperature has risen above her regular temperature.
- All women can use the BBT method except those with fever.

3. Cervical Mucus Method (CMM)

Cervical Mucus Method is a symptoms-based fertility awareness method. The method relies on the woman's ability to predict her fertile days by following the characteristics of cervical mucus (Figure 4.3). This method is also an ovulation method used by women trying to get pregnant and have a child.

a) Early mucus

b) Transitional mucous

C) highly fertile mucous

Fig 4.3 Types of cervical mucus

Mechanism of action:

The method works primarily by helping a woman know on what days she could become pregnant and the couple avoids unprotected vaginal sex during the fertile days.

As soon as she notices any secretions, she considers herself fertile and avoids unprotected sex. She continues to check her cervical secretions each day. The secretions have a "peak day"-the last day that they are clear, slippery, stretchy, and wet. She will know this has passed when, on the next day, her secretions are sticky or dry, or she has no secretions at all. She continues to consider herself fertile for three days after that peak day and avoids unprotected sex

Instruct women to:

- Use a chart to record their mucus pattern.
- Look at their cervical mucus in the morning, and every time after using the toilet, using a clean cloth or tissue paper to determine the colour and consistency of the mucus.
- Touch the secretion for determining its stretchiness and slipperiness (see figure 4.3)
- Feel how wet the sensation is in their genitalia when they are walking.
- Abstain from sexual intercourse on the day when mucus appears,

Advantages:

- Increased communication between the couple.
- Increased awareness on how to get pregnant if a conception is desired.

Disadvantages:

It has a high failure rate because it needs several days of abstinence and a lot of experience in using the method to be effective. It is also difficult to use this method in the case of vaginal infections; secretions may be misleading.

Effectiveness:

With consistent and correct use, three pregnancies per 100 women using cervical mucus method will get pregnant in the first year. So, 97 of every 100 women relying on cervical mucus method will not become pregnant.

Lactational Amenorrhea Method (LAM)

Lactational Amenorrhea Method (LAM) is a temporary family planning method based on the natural effect of breastfeeding on fertility. ("Lactational" means related to breastfeeding; "Amenorrhea" means not having monthly bleeding)

The lactational amenorrhea method (LAM) requires three conditions and must be met:

- The mother's monthly bleeding has not returned.
- The baby is entirely or nearly fully breastfed and is often fed, day and night.
- The baby is less than six months old.

If any one of these three criteria changes, another contraceptive must be started immediately to prevent an unwanted pregnancy, and to ensure healthy birth spacing of at least three years.

Any factor that causes a decrease in suckling can result in the return of ovulation and decreased milk production. These factors include supplemental feeding of the infant, reduction in the number of breastfeeds or long intervals between breastfeeds, maternal stress and maternal/child illness. In these cases, the client should not rely on LAM.

Advantages:

- Effectively prevents pregnancy for at least six months.
- Cheap.
- Encourages the best breastfeeding.
- Does not interfere sexual intercourse.
- No hormonal side effects.
- Can be used immediately after birth.
- Not a suitable method if the mother is working outside the home.
- If the mother has HIV, small chance to transmit the infection
- No protection against STIs including HIV.
- Not effective after 6 months.

Effectiveness:
Effectiveness depends on the user: Risk of pregnancy is greatest when a woman cannot entirely or nearly fully breastfeed her infant. As commonly used, about two pregnancies per 100 women using LAM in the first six months after childbirth will occur. This means that 98 of every 100 women relying on LAM will not become pregnant.

Withdrawal Method (Coitus Interrupts)

Removal or pulling out (coitus interruptus) method, a man pulls his penis out of the woman and away from her genitals before he ejaculates. This method is the least effective method and not advisable. Sometimes a man is not able to pull out before he ejaculates. Even if the man pulls out in time, some liquid that contains sperm can leak out of his penis before ejaculation and cause pregnancy.