Much Ado Without Rhythm
Inclusion of Standard Days Method ignites debate over natural family planning
By Mike Gomez
Even as varying schools of thought in obstetrical and gynecological circles argue over the finer points in reproductive medicine, the great societal debates over family planning issues rage with greater fervor than ever before. This is especially true in the Philippines, tagged as "overpopulated" but seen as the ever-brightening beacon of Christianity in this part of the world.
The Roman Catholic Church has long studied the medical, social, and moral issues surrounding human procreation, issuing a continuous stream of guidelines that the entire world, Christian or not, is compelled to take seriously. These pronouncements have had their influence on legislation and governance in the Philippines, not only because the majority of our officials are Christians, but because the precepts are also founded on sound humanistic and scientific principles.
Such teachings go beyond the principles articulated in Humanae Vitae and other Church encyclicals. They also take reproductive health into consideration, with particular stress on the diverse effects of contraception and abortion on women, and surgical sterilization on both sexes.
Defining responsible parenthood as the "prudent and generous use of the couple's gift of sexuality in order for them to beget the right number of children according to God's plan," the Church acknowledges the value of family planning in postponing pregnancy when appropriate. Even if certain sectors within the Church believe that married couples should have as many children as possible, Church authorities encourage married couples to learn safe and effective ways of postponing pregnancy. These means are limited to the way of life referred to as natural family planning (NFP).
NFP or not NFP
To be sure, NFP advocates have yet to agree on its clear-cut definition. Government seems inclined to include any method that seeks to prevent or postpone pregnancy by abstaining from sexual intercourse when the female partner is believed to be fertile. The government program also coaches couples intent on bearing children to engage in sexual intercourse when the wife is believed to be fertile.
But the Church and the many groups that teach NFP limit the definition to the use only of "natural" methods of determining whether or not the woman is fertile, excluding any method governed by a calendar, a computer program, an electronic timer, a schedule, or a mnemonic device like a string of beads. NFP advocates stress that the only surefire means of determining a woman's fertility status is by drawing observations from the woman herself. Which limits the means to the mucus or Billings Ovulation Method, the Basal Body Temperature Method, and the Sympto Thermal Method, which is a combination of the first two. The Lactation Amenorrhea Method is often associated with NFP, but is solely a means of postponing subsequent pregnancy postpartum, and not a means of achieving pregnancy.
Many Filipinos still associate NFP with the long-discarded rhythm method that was officially excluded from the government's prescribed methods not only because of the low acceptability rate, but also because it was deemed scientifically unsound and inaccurate.
The rhythm method worked on the presumption that the woman's pre-ovulatory, ovulatory, and post-ovulatory phases follow a similar pattern month after month. Such is not the case for majority of women, argue the teachers of the other methods of NFP that rely solely on observations in or by the woman herself, and not on a schedule derived from some exercise in evidence-based medicine.
Standard Days?
Although the accepted definition and inclusion criteria of NFP methods seemed clear enough for some time, the horizon became fuzzy with the introduction and acceptance of the Standard Days Method (SDM). Developed by Georgetown University, SDM also prescribes abstinence from sexual intercourse during fertile days when the couple prefers to postpone pregnancy, but it assigns those fertile days with the means of a "standard" set of colored beads.
SDM limits the woman's observation and awareness of her own body to a watchful vigil for the first day of menstruation, which she notes on an especially-designed rosary- or necklace-like string of colored beads. The necklace contains a red bead to indicate the first day of menstruation, followed by six brown beads that indicate infertile or "safe" days. These are followed by 12 white beads that indicate fertile days (8-19) during which couples are to refrain from unprotected intercourse. Following these are the remaining 13 beads in the 32-bead necklace which, again, indicate infertile or "safe" days (20-32).
The seventh of these final 13 beads, however, is a chocolate brown bead indicating that the woman has a short ovulation cycle of less than 26 days if she experiences her subsequent period before arriving at that bead. At the end of the entire loop, immediately before the initial red bead, is a small black bead to indicate that the woman has a long cycle, which is over the 32 days, if she has arrived at that bead and has still not experienced her next menstruation. For cycles found to be too short or too long, the method will not be applicable to the user.
Pro-life advocates and natural family planning organizations raised a furor over the unfounded presumptions this method is based on, arguing that it is doomed to fail, and would very likely only give NFP a bad name. They pointed out that only a limited number of women would be fit for this method, and even those who are, could not be certain of experiencing a clock-like ovulation pattern every menstrual cycle.
Noted obstetrician-gynecologist and officer of the Philippine Society for Reproductive Endocrinology Dr. Eileen Manalo said that only about five percent of women have predictable cycles to benefit from such method. She indicated that the gold standard in NFP is achievable by applying the three accepted modern methods in combination. Observing bodily symptoms, moods, physical manifestations, basal body temperature, and cervical mucus or discharges would give a woman a pretty accurate indication of fertility status.
A trainor from the Institute for Reproductive Health (IRH) indicated that, aside from looking out for the first day of menstruation, women using the SDM should not pay heed to any other observation like vaginal discharge, feelings of bloatedness or discomfort, skin conditions, tenderness of breasts, temperature. But to this is unacceptable to NFP advocates, who stressed that it is unnatural and patently inaccurate to trust anything other than the woman's own body when determining whether or not she is fertile.
Sister Pilar Verzosa of Pro-Life Philippines described SDM as "rhythm with a mnemonic," referring to the necklace that replaces the usual calendars or charts. Other stalwarts in the NFP sector went as far as to describe the method as "rhythm for idiots."
But Dr. Loreto Roquero, who heads the Philippine Family Planning Program, is unfazed by such criticisms. He noted that the method has displayed 95-percent effectiveness when applied correctly-with strict adherence to the rules and principles of abstinence on indicated fertile days. "Even if you want to call it rhythm, should we dismiss the method that has proved effective?" Dr. Roquero asked.
Contradictory Policies
On the other hand, Esperanza A. Dowling, executive director of the Philippine Federation for Natural Family Planning and DoH consultant, pointed out that Health Secretary Manuel Dayrit's September 2001 Administrative Order adopting SDM contradicts Department Circular No. 130 issued by former Secretary Carmencita Reodica in May 1997. Dr. Reodica's issuance defines NFP as an "educational process of determining the fertile and infertile periods of a woman by observing physiological signs and symptoms of the menstrual cycle so that intercourse may be timed to avoid or achieve a pregnancy." Circular No. 101 issued in June 1994 officially dropped the calendar/rhythm method from the mix of NFP techniques offered.
Ms. Dowling pointed out that SDM does not fit the definition of NFP under the circular since the method does not involve observation of signs and symptoms, but relies on an artificial means of pronouncing when the woman is fertile or infertile. She added that Circular 101 also prohibits the implementation of SDM in the Philippines because of the agreed-upon premise that it is but rhythm method in a new package.
Some Church leaders, however, did not readily realize this distinction and quickly accepted the method and grasped the hand of cooperation extended by government. But Manila Archbishop Jaime Cardinal Sin recently clarified that a Church and State collaboration on family planning issues would be welcome, though "no such agreement has yet been entered into, neither are there any preliminary talks whatsoever leading to such an end."
The Cardinal's letter also reinforced the Church's support for the Billings Ovulation Method and the Sympto-Thermal Method, while clearly describing SDM as a repackaging of the outdated calendar or rhythm method. His letter reiterated an earlier Church position against collaborating with a party that is at the same time implementing a "cafeteria system," which includes the promotion of contraceptives. As always, the Cardinal's pronouncement preached strongly against the use of abortifacients, which drew attention due to a brewing controversy over the delisting of an emergency contraception pill.
Morning-After Melee
Even as pro-life groups are uncomfortable with recent developments in the family planning program, they are supportive of the DoH Secretary's firm position against allowing the emergency contraceptive, Postinor (levonorgestrel) in the Philippines. The term "emergency contraception" refers to an action taken within 72 hours after sexual contact to prevent an unwanted pregnancy.
Sec. Dayrit concurred with a Bureau of Food and Drug decision to delist Postinor because of its acknowledged abortifacient effect. The Constitution, by mandating the State to protect human life at the moment of conception, clearly prohibits abortion. This provision has often been the subject of debate. Some sectors choose to abide by a WHO and UNFPA definition of human life as an implanted embryo while most others agree that human life is already present in the fertilized egg, or zygote. Postinor's product information admits that the drug would make the zygote unable to implant on the endometrium, thereby terminating the pregnancy.
Sec. Dayrit consulted some of the authors of the Constitution to know their true intent in defining the beginning of human life. From these discussions, he drew his conviction that human life is present immediately upon successful fertilization of the human egg by the human sperm because the resultant zygote already has the complete set of four chromosomes to develop into a unique human being. "Life begins when the gametes are complete," he said.
The Secretary said any action taken to prevent this zygote from developing into that human being is equal to abortion because withholding such intervention would result in childbirth. To him, "emergency contraception" is but a euphemism for abortion.
Sec. Dayrit asserted that he is not insensitive to the plight of the rape victim who may not want to continue with an unwanted pregnancy. But he stressed that the State must also respect and protect the life of the unborn child even as it respects the rights of the woman carrying that child. While certain sectors clamor for the allowing the use of emergency contraception to allow women to exercise their rights over their own body, these women do not possess a right to determine whether a child is to live or die since that child is now protected by the law.
Sec. Dayrit raised four points. First: Knowing the product is admittedly abortifacient, registering it with the BFAD already breaches the antiabortion principle of Philippine laws. Second: The drug may be difficult to regulate as people presently source other underground means of chemical abortion, including some herbal preparations, whether or not rape is involved. Third: Emergency contraception is not always practicable since most victims of rape do not report the incident immediately. Finally, there is no value in adding one wrongdoing (abortion) over another (rape).
What is important, he stressed, is to do what can be done to prevent rape, and to empower the people to prevent unwanted pregnancies since most abortions are not secondary to rape but to unwanted pregnancies among consenting sex partners or spouses.
More Oomph
The introduction of the SDM is only one facet, albeit a major one, of the new impetus Sec. Dayrit has given the program. Another Administrative Order strengthens the total program on four fronts. These are the mandatory establishment of itinerant voluntary surgical contraception teams for all DoH hospitals, strengthening of NFP to match the level of usage experienced by artificial methods, providing family planning services to the urban poor, and strengthening the program in regions with highest unmet needs and the lowest contraceptive prevalence ratio.
The Secretary pointed out that much of the government program in the past involved policies and initiatives insufficiently backed by trained personnel. The current budget allocation for the PFPP is heavy on training, capacity building, counseling, policy formulation, and preparation of information, education, and communication materials, Dr. Roquero disclosed.
Even as accusations against the use of funds for "population control" continue to fly, the DoH is actually spending none of the Philippine government's funds on contraceptives, relying once again on the USAID for the needed materiel and supply.
PFNFP's Ms. Dowling views this as good news since it would seem to translate to greater allocation for NFP. Whether or not it is due to the money saved on contraceptives or any other allocation, there will definitely be more resources available for NFP.
Ms. Dowling pointed out that an overwhelming slice of the entire family planning pie is accounted for by artificial methods. Out of 100 Filipino women, she illustrated, 43 use family planning methods of any kind, with 17 percent of all women still using the ineffective "traditional" methods of rhythm and withdrawal. Twenty-six percent of all women in the Philippines use some form of artificial or permanent method of family planning.
Out of the 57 percent non-users, 20 percent of total women are trying to achieve pregnancy while 37 percent do not use any method of contraception because they are afraid of side effects.
Most shocking is the minuscule two-tenths of one percent who use any of the modern accepted methods of natural family planning. Dr. Roquero is tasked with raising this figure astronomically to the level of those who use artificial methods. This is a tall order as there has been "no investment in the past," he indicated, lamenting the dearth of training among health workers on teaching modern family planning methods.
The Other Front
Indeed, the vast majority of Filipino families fall within the healthcare delivery concern of the government system, whether by the DoH, local governments, or even the Philippine Health Insurance Program. One should not discount, however, the small, but not to be ignored sector of Filipino society who seek natural family planning services at the clinics of their family physician or ob-gynecologist.
Dr. Manalo said there are patients who clamor for NFP methods. And while ob-gynecologists may find teaching NFP more time-consuming than offering an artificial method, she noted that it is supposed to be standard practice for ob-gynes to bring up family planning concerns with their patients during postpartum visits.
Recent data gathered by the National Statistics Office show that the professional sector is least inclined to use contraceptives or subject themselves to sterilization and abortion. They are also the most likely to choose and be able to successfully apply a modern method of natural family planning. It is perhaps for this reason that the Catholic Church, with its pro-life and NFP advocacy, is viewed by some sectors as elitist. It is precisely this outlook and possibly this reality that the Church-backed NFP teachers and the government NFP workers hope to reverse in the next few years.
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