Libido and Sexual Behaviour in the Fertile Phase - NFP

Transcription

Medical School of Granada, Spain
Libido and
Sexual
Behaviour in
the Fertile
Phase
OBJECTIVE
• To determine if a perceived rise
of sexual desire during the
fertile phase might be an
influence on the breaking of the
abstinence rule, the basic rule
of NFP
Enriqueta Barranco Castillo, MD, PhD, Profesor of Obstetric and Gynaecology,
Granada, Spain
Françoise Soler, STM ‘s teacher, ACODIPLAN, Barcelona, Spain
Material and Methods
• 15 women users of STM
• Charting changes of sexual
desire during 2-3 cycles in a
diary calendar of symptoms
• Charting of sexual behaviour
during this time
Results I
•
•
•
•
•
Analysed cycles : 37
mean age: 32.72 years (TD 5.18)
N children: 0.86 (TD 1.02)
Education: 75% College
Work away from home: 87.5%
(mean hours 7.77/day)
• Married 43.8%, unmarried 43.8%
• Religion: Roman Catholic 62.5%
Barranco: Libido
Impulso sexual
Aumenta
disminuye
User’s
Code
Chart 000467
Results II
• Have declared the intention of
avoiding pregnancy prior to
participation to the study 93.8%
• Previous experience with Billings
method: 6.2%
• Previous experience with STM:
87.5% (mean 24.44 months)
Results III
•
•
•
•
•
•
•
•
•
Use of contraception method previously
STM: 31.3%
BBTM: 18.8%
Withdrawal: 37.5%
Condom: 75%
Pill: 18.6%
IUD: 12.5%
Diaphragm: 12.5%
Spermicides: 6.3%
The fertility symptoms
in the STM charting
• The fertile phase was between 11-12
days in 37.9% of the cycles
• The first day of the cervical mucus
was between 9-12 days of the cycle
in 59.9% of the charting
• The mucus peak day was between
14-19 days of the cycle in 56.7% of
the charting
• The rise of temperature was
between 14-20 days of the cycle in
64.8% of the charting
Conclusion
• In our study group, during the fertile
phase there was a significant rise in
sexual desire in more than half of
women, but the sexual activity
during this phase had no correlation
to this rise. The abstinence (no
intercourse) rule was respected
above other sexual behaviour
Barranco: Libido
Increase in libido during
the menstrual cycle n = 19
Fertile phase
Infertile phase
For one day
51.4% n = 19
For 1 day
13.5% n = 5
For 2 days
40.5% n = 15
For 2 days
13.5% n = 5
For 3 days
24.3% n = 9
Decrease
For one day
18.8% n = 7
Decrease
For 2 days
21.6% n = 8
Not
indicated
on return
48.6%
n = 18
Statistic correlations
(T Student)
n = 19 cycles
Number of fertile days
Rise of sexual desire
P = 0.5
First day of cervical
mucus
P = 0.001
Mucus Peak day
P = 0.028
Rise of temperature
P = 0.003
Unprotected intercourse during
the fertile phase
P = 0.12
Protected intercourse during
the fertile phase
P = 0.25
Charting of intercourse during
the fertile phase
P = 0.86
Natural methods, gender and
sexuality
Background
Gender equity included in Millennium
Development Goals
Widespread introduction of natural methods
has the potential to address gender equity
and sexuality
European Congress on Fertility
Awareness-Based Methods
September 2008
National access to simple, newer natural
methods may be achieved in 3-5 countries by
2010
The Standard Days Method
Helps couples prevent
pregnancy by knowing
which days they should
avoid unprotected
intercourse
CycleBeads®
The SDM is used with CycleBeads, a colorcoded string of beads to help a woman:

Identifies days 8-19 of
the cycle as fertile
Track her cycle days
Know when she is fertile
Monitor her cycle length
Involve her partner
Works best for women
with menstrual cycles
from 26 to 32 days
TwoDay Method
YES
Did I note any
secretions
today?
I can get pregnant today.
NO
YES
Did I note any
secretions
yesterday?
I can get pregnant
today.
SDM and TDM Introduction Studies
16 service delivery settings in 7 countries
in Asia, Latin America and Africa
Reproductive
health programs,
FP agencies and
community
development
NGOs
NO
Pregnancy is not likely today.
Lundgren: Natuural methods
1
Quarterly interviews:
1600 male and female
SDM users
822 female TDM users
Focus groups and indepth interviews:
current and
discontinued female
and male users
Gender-related Study
Questions
Can men use natural
methods?
How does NFP use
influence the couple
relationship?
How does NFP use
affect women’s
autonomy?
Percent of Cycles with
Reported Intercourse
n=4025 cycles
CAN MEN USE NATURAL
METHODS?
Managing the Fertile Days
n=3928 cycles
Men participate in SDM use by…
Using a condom or
abstaining during fertile
days
Following wife’s
instructions
Keeping track of fertile
days
Purchasing CycleBeads
and condoms
2
Women’s Opinion of the SDM
HOW DOES NFP USE
INFLUENCE THE COUPLE
RELATIONSHIP?
Mean Coital Frequency by Cycle
(SDM and TDM use)
Comparison of Mean Coital Frequency
5.5 per cycle*
Coitus-dependent
methods
4.9 per cycle*
SDM Users
5.5 per cycle
TDM users
5.6 per cycle
Days with intercourse per cycle
6.0
All sexually active women
5.8
5.6
5.4
5.2
5.0
0
4.8
4.6
1
*Stover et al, 2001
Dimensions of Sexual
Satisfaction Framework
Physical
Emotional
zLove
WellWell-being
zSide
effects
zMenstrual changes
zRespect/appreciation
zHarmony
zLocus
zMoral
of control
congruence
zOpportunity/scarcity
Sexual
Pleasure
zEnhanced
desire
zSensation
zErotic
zRelaxation
zRespite
touching
2
3
4
5
6
7
8
9 10 11 12 13
Cycle number
Key Themes
No change reported by many couples
Some report dissatisfaction with the fertile
days
Most report enhanced feelings of control,
love, mutual respect and physical well
being
Heightened eroticism related to timing of
sex and non-coital practices
zLibido
3
Effect of SDM on the couple
relationship (India)
Effect of TwoDay Method on
the Couple Relationship (Peru)
92% of rural users in India report that SDM use
had a positive influence on their relationship
citing…

increased partner communication
Improved ability to negotiate sex
increased affection/understanding
improved sexual relations due to confidence in fertile
days
8% cite a negative influence
Husband angry/uncomfortable
Source: Exit Interviews
In their words…
Influence on their
relationship
“The SDM has helped us to come closer, understand each other’s
needs. Unlike earlier, we now discuss intimate things with each
other and this has added pleasure to our otherwise monotonous
sex life.”
- male SDM user, India
In women’s words…
Influence on their relationship
“During the abstinence period, my
husband spends more time with me
going out and visiting family.”
-India
“During the 12 days when I am fertile,
my husband and I share stories. I
become a story teller on my fertile
days.”
-Philippines
“I feel good that my husband now understands how my body works.
He pays attention to my suggestions and respects my wishes. For
the first time he asks me if we can have intercourse. I am happy
that he cares about me.”
-female SDM user, India
In men’s words…
Influence on sexual pleasure
“I think that abstinence contributes to enjoying sex more,
because we have greater desire.”
-Honduras
“How can I explain it..when one sleeps apart and you have to
make an appointment, things get good.”
-El Salvador
“It seems like two months have gone by and we never move
beyond these white beads.”
-Philippines
In women’s words…
Influence on sexual pleasure
“We get to the moment in which we begin to caress each other,
even the genitals, and we get to the point when the man as well as
the woman feels good. How do you say it? When we finish. But
there is not sex.”
-Honduras
“Unlike when I used pills, I always had a headache. You can have
sex every day but you wouldn’t like it because you felt dry. My
husband noticed that. When I used the SDM, it seemed natural, like
we were newlyweds again.”
-Philippines
4
Comparison of Scores on
Gender Equity Index pre/post SDM Use
(Guatemalan Women)
HOW DOES NFP USE AFFECT
WOMEN’S EMPOWERMENT?
Comparison of Scores on
Right-to-Refuse Sex Index
(Indian Women)
Women gained confidence and felt
empowered by knowledge of
menstrual cycle
“Knowledge of safe and unsafe period
has been liberating.”
- El Salvador
“Now we know about our bodies and how
to protect ourselves during the unsafe
days. Because of the necklace we know
how our period comes.
- Benin
Key Findings
Men are interested in NFP
Most men are able to use
NFP correctly
DISCUSSION
Many couples report
enhanced sexual pleasure
and strengthened partner
relationships
5
Key Findings
Introducing NFP can strengthen efforts to improve
gender equity by addressing couple issues and involving
men in family planning.
Continued expansion of NFP requires efforts to position
natural options as methods that engage men
constructively and enhance couple relationships.
WWW.IRH.ORG
6
Background (1)
Antwerp pupils' opinions about Family
Planning methods with postfertilization
effects
Biologically a new human being starts at the
fertilization of an ovum by a sperm
Î 2 opinions:
z
E Govaerts*, RT Mikolajczyk, P
Hernalsteen, JB Stanford et al.
z
From this scientific fact, some give the embryo
rights in agreement with all the human rights of the
Declaration of Human Rights.
Others have the opinion that there would be a
graduality and build in several for the juridical
status of the embryo unsure arguments.
*AZ St.-Jozef in Turnhout
Background (2)
Informed consent and patient rights:
z The communication with the patient should be
in a clear language. (Art. 7 §2)
z The information given to the patient, to give his
consent as meantin § 1, concerns the
objective, […] the for the patient relevant
contra indications, side effects and risks […],
the possible alternatives and the financial
consequences. (Art. 8 §2)
Method
girls 5th-6th year secundary school.
z 19 public and private schools in the
province of Antwerp (27,5% of 69
contacted schools).
z Questionnaire with 41 questions in 8
areas related to fertility and attitudes
towards family planning methods, use
and past use.
z 705
Research question
z Does
belonging to one or the other
opinion play a role in the attitude towards
a family planning method?
Population
n = 705
%
Belgian
88,0
n = 705
%
Dutch
2,6
Italians
1,4
Technical SS 44,9 (27)
Moroccan
2,6
Turkish
1,8
Other
3,3
Professional
SS
Artistic SS
(total
population)
General SS
22,7 (44)
32,2 (26)
0,1 (2)
Govaerts: Antwerp pupils
1
Philosophy of life – Practice
n = 705
%
n = 705
The ethical questions
%
z
z
Catholic
79,8
> or 1/week
6,8
Protestant
1,6
1/month
4,2
Muslim
6,3
0,9
Some
times/year
25,9
Witness
Jehova
< 1/year
33,3
Other
11,5
never
29,8
The method of birth control is… acceptable
from my moral / ethical point of view
About 28 family planning methods was asked if they
would use them or not and if the knew them.
Thereafter follows the question why they choose a
specific method.
z
Question 12: “Below is a list of different features (12) methods
of birth control may have. Please let us know how important
the features are for you.”
1. Acceptable from my ethical / moral point of view.
Ethical reflections
No opinion
No opinion
Very important
Very important
..
.
Do not know
…
.
Not important at all
0
..
…
Not important at all
0
10
20
30
40
Info working of the methods
Stage 2
after fertilization
before implantation
Stage 3
after implantation
10
20
30
40
Yes
Question 14: “In your opinion, are
there any important ethical issues
No
(anything that makes you feel that
using the specific method would be
right or wrong) to consider in
Missing
choosing a method of birth
control?”
0
20
40
60
Information
Should your
GP/gynaecologist tell
you details how the
method works?
Pre implantation
Post implantation
60,0
50,0
40,0
30,0
20,0
Stage 1
before implantation
10,0
0,0
Yes
No
Unsure
Missing
2
Stop the use of a method
Opinion about the use of a method
z
Would you consider using a
birth control method that
z stops the release of the
egg from the ovary
(stage 1)
z acts after fertilization, that
avoids a fertilized ovum to
develop
(stage 2)
z acts after nidation in the
uterus
(stage 3)
z
Pre ovulatory
Post implantation
Pre implantation
60,0
50,0
40,0
z
30,0
If you were using a birth control
method, and you learned that
z it sometimes works after
fertilization but before
implantation (stage 2),
z it sometimes works after
implantation in the uterus
(stage 3),
would you stop or continue using
the method?
10,0
0,0
No
Unsure
Missing
Stop
Pre implantation
Post implantation
Do not know
Other
50
More than one
time in 100 years
More than one
time in ten years
More than one
time in one year
In more than half
of the cycles
10
0,0
10,0
20,0
30,0
40,0
0
Yes
No
Unsure
z
z
The GP/midwife stands in the non-judgment
counseling.
The patient has right to information that takes
care of his/her ethical sensibility.
Which questions should be asked before
starting contraception use?
z
z
z
Missing
In a deconfessionalized society ethical
aspects don’t play a role for 23%.
2. In a society, where contraception has
been in use for 50 years, theoretical
ethical aspects for the choice of a
method are still important to 55%.
3. Methods that act after fertilization seem
to be a problem for about 30% of the
study population.
50,0
Missing
Conclusion
z
Unsure
1.
Missing
20
Continue
Observations
Post implantation
30
30,0
20,0
Loss of embryo Frequency during
pre-/ postimplantation
40
40,0
10,0
Yes
60
Post implantation
50,0
20,0
0,0
Pre implantation
Pre implantation
60,0
Does the patient have ethical problems with
possible postfertilization effects of a method?
Which information is important to make a choice?
Is a sympto thermal NFP method proposed as
alternative?
Possible approach
z
“Most of the time, the pill acts by preventing an
egg from forming. This prevents pregnancy.
However, women on the pill can still
sometimes get pregnant. Some doctors think
that the pill may cause the loss of some of
these pregnancies very early in the pregnancy,
before you would even know you were
pregnant. Would knowing more about this
possibility be important to you in your decision
about whether to use the pill?”
Larimore, Stanford: Postfertilization Effects of Oral Contraceptives
and Their Relationship to Informed Consent (ARCH FAM MED/VOL 9, FEB 2000
3
www.unav.es/preventiva/sexualidad_fertilidad
SPANISH WOMEN’S OPINIONS ABOUT
FAMILY PLANNING METHODS WITH
POSTFERTILIZATION EFFECTS
Index
1.
2.
3.
4.
5.
Authors:
Lopez del Burgo C., Lopez de Fez CM., Lopez Guzman J., De Irala J.
Affiliation:
Preventive Medicine and Public Health, University of Navarra (Spain)
Biomedical Humanities, University of Navarra (Spain)
Acknowledgements:
This research was supported by a grant from the Institute of Sciences
for the Family of the University of Navarra (23017323).
Introduction
Objectives
Methods
Results
Conclusions
We thank to Dr. Joseph B Stanford (University of Utah) and Dr. Rafael
T Mikolajczyk (University of Bielefeld) who first studied this issue in the
USA and created the first version of the questionnaire
Contact: [email protected]
[email protected]
1. Introduction
1. Introduction

www.unav.es/preventiva
Some methods of family planning (FP) occasionally
work after fertilization

Knowing about postfertilization
important to some women
Postfertilization effects*:
may
be
Decision of using a method that
may act after fertilization
• Hormonal contraceptives
40%
NO
• Emergency contraceptive pill
FERTILIZATION
effects
38%
YES
22%
UNSURE
• Intrauterine devices (IUD)
IMPLANTATION
Decision of using a method that
may act after fertilization
www.schering.es
53% NO
* Quality of evidence: Fair
The U.S.Preventive Service Task Force grades the quality of
the overall evidence on a 3-point scale (good, fair, poor)
2. Objectives
Index
1.
2.
3.
4.
5.
To
explore
the
Spanish
women’s
attitudes towards the mechanisms of
action of Family Planning methods
Introduction
Objectives
Methods
Results
Conclusions
• To identify beliefs and characteristics
possibly associated with those attitudes.
[email protected]
Lopez del Burgo: Spanish women’s opinion
1
3. Methods
Index
1.
2.
3.
4.
5.
Cross-sectional
survey in a Spanish
representative sample
Introduction
Objectives
Methods
Results
Conclusions
¾ GFK-Emer Market Research Company
¾ Random stratified and multistage sampling
¾ 848 potentially fertile women, aged 18-49
Data collection:
¾ March-September 2005
¾ Computer-Assisted
Personal
Interviewing
(CAPI) method
[email protected]
3. Methods
Index
Data collection:
¾ 30-item, anonymous questionnaire about FP*
Univariate and multivariate logistic regression
analyses (SPSS, 13.0 version)
1.
2.
3.
4.
5.
Introduction
Objectives
Methods
Results
Conclusions
Ethic Committee approval for the study
*The questionnaire was originally developed in English by Dr. J. Stanford
(University of Utah, USA) and Dr. R. Mikolajczyk (University of Bielefeld,
Germany) and subsequently modified and adapted by the authors of the
Spanish study.
[email protected]
4. Results
4. Results
Characteristics of the sample:
¾ Age .……….……………………
25-34 years (39%)
¾ Education ..…………….………
High school or compulsory school (<16y) (78.7%)
¾ Marital status …………………
Married (57.5%)
Women’s opinion about human life beginning:
OTHER* 28.7%
40.5%
FERTILIZATION
¾ Religion …….………………….. Catholics (78.9%), church attendance ocasionally
¾ Nº live births ………………….. 0 (48.4%)
¾ Desire for future pregancy ..
Yes (64,7%)
16.5%
AFTER
IMPLANTATION
14.3%
IMPLANTATION
* Other: “there is no exact time”, “I am not sure”, “I do not have an opinion” and
“sometime before fertilization”.
2
Resultados
4. Results

Resultados
4. Results
Women’s attitudes about postfertilization effects:

Would you consider using a birth control method that sometimes
works after fertilization or after implantation?
After fertilization, the
egg develops into an
embryo with many cells.
100
100
After implantation in the
uterus, the embryo develops
into a fetus.
75
FERTILIZATION
The egg unites
with the sperm.
50
45%
UTERO
OVARIO
33%
50
22%
Before fertilization,
the egg is released
from the ovary.VAGINA
25
FERTILIZATION
The egg unites
with the sperm.
25
Would you consider using a birth control method that sometimes
works after fertilization or after implantation?
100
into a fetus.
75
57%
YES
NO
20%
50
23%
the egg is released
After Fertilization but before
Implantation
75
33%
45%
22%
25
NO
UNSURE
25
23%
20%
0
YES
NO
YES
UNSURE
Implantation
After Implantation
57%
50
0
YES
UNSURE
100
75
UTERO
OVARIO
0
0
NO
After Implantation
Resultados
4. Results

Resultados
4. Results

Women’s decision about continuing the use of a method after
learning it may work after fertilization or after implantation
100
100
into a fetus.
75
50
48%
FERTILIZATION
The egg unites
with the sperm.
27.5%
75
50
UTERO
OVARIO
25
24.5%
FERTILIZATION
The egg unites
with the sperm.
the egg is released
0
STOP
USING
CONTINUE
USING
100
into a fetus.
62.6%
UTERO
OVARIO
25%
12.4%
25
Women’s decision about continuing the use of a method after
learning it may work after fertilization or after implantation
100
75
75
50
48%
27.5%
24.5%
CONTINUE
USING
UNSURE
After Implantation
STOP
USING
CONTINUE
USING
UNSURE
Implantation
Women who:
¾ Believe that human life begins at fertilization…
¾ Consider it is important to distinguish between
spontaneous and induced embryo loss…
¾ Refer having a religion…
… were less likely to consider the use of a method
with postfertilization effects*.
* Results from multivariate analyses. All logistic regression models were
adjusted for age, education, country of origin, annual income, marital status, desire
for future pregnancy, number of pregnancies, number of elective abortions,
religion, opinion about human life begining and about embryonic loss’ cause.
STOP
USING
CONTINUE
USING
UNSURE
After Implantation
Resultados
4. Results
25%
12.4%
25
0
0
STOP
USING
62.6%
50
25
the egg is released
0
UNSURE
Implantation

UNSURE
Index
1.
2.
3.
4.
5.
Introduction
Objectives
Methods
Results
Conclusions
[email protected]
3
5. Conclusions
SPANISH WOMEN’S OPINIONS ABOUT
FAMILY PLANNING METHODS WITH
POSTFERTILIZATION EFFECTS
Potential postfertilization effects of family planning
methods may influence women’s choice of a particular
FP method.

Authors:
Lopez del Burgo C., Lopez de Fez CM., Lopez Guzman J., De Irala J.
Postfertilization effects of family planning methods
should be disclosed to women in order to achieve
informed choices.
Affiliation:
Preventive Medicine and Public Health, University of Navarra (Spain)
Biomedical Humanities, University of Navarra (Spain)
Contact:
[email protected]
[email protected]
Scientific evidence about the mechanisms of action
•
Trussell J, Ellertson C, Stewart F, Raymond EG, Shochet T. The role of emergency
contraception. Am J Obstet Gynecol 2004; 190: S30-8.
•
Larimore WL, Stanford JB. Postfertilization effects of oral contraceptives and
their relationship to informed consent. Arch Fam Med 2000; 9: 126-33.
•
•
The Practice Committee of the American Society for Reproductive Medicine.
Hormonal contraception: recent advances and controversies. Fertil Steril
2004; 82 Suppl 1: S26-32.
Mikolajczyk RT, Stanford JB. Levonorgestrel emergency contraception: a joint
analysis of effectiveness and mechanism of action. Fertility and Sterility 2007;
88: 565-71.
•
•
Frye CA. An overview of oral contraceptives: mechanism of action and
clinical use. Neurology 2006; 66: S29-36.
Lahteenmaki P, Rauramo I, Backman T. The levonorgestrel intrauterine system
in contraception. Steroids 2000; 65: 693-7.
•
•
Wertheimer RE. Emergency postcoital contraception. Am Fam Physician 2000;
62: 2287-92.
Stanford JB, Mikolajczyk RT. Mechanisms of action of intrauterine devices:
update and estimation of postfertilization effects. Am J Obstet Gynecol 2002;
187: 1699-708.
•
Wellbery C. Emergency contraception. Arch Fam Med 2000; 9: 642-6.
•
•
Kahlenborn C, Stanford JB, Larimore WL. Postfertilization effect of hormonal
emergency contraception. Ann Pharmacother 2002; 36: 465-70.
French R, Van Vliet H, Cowan F et al. Hormonally impregnated intrauterine
systems (IUSs) versus other forms of reversible contraceptives as effective
methods of preventing pregnancy. Cochrane Database Syst Rev 2004:
CD001776.
•
American College of Obstetricians and Gynecologists (ACOG). Emergency oral
contraception. Number 25, March 2001. (Replace Practice Pattern Number 3,
December 1996). American College of Obstetricians and Gynecologists. Int J
Gynaecol Obstet 2002; 78: 191-8.
* Quality of evidence: Fair
Quality of Evidence
The USPSTF (US Preventive Service Task Force) grades the quality of the
overall evidence for a service on a 3-point scale:
• Good:
Evidence includes consistent results from well-designed, wellconducted studies in representative populations that directly assess
effects on health outcomes.
• Fair:
Evidence is sufficient to determine effects on health outcomes, but
the strength of the evidence is limited by the number, quality, or
consistency of the individual studies, generalizability to routine practice,
or indirect nature of the evidence on health outcomes.
•Poor:
Evidence is insufficient to assess the effects on health outcomes because
of limited number or power of studies, important flaws in their design or
conduct, gaps in the chain of evidence, or lack of information on
important health outcomes.
U.S. Preventive Services Task Force Ratings: Strength of Recommendations and Quality of Evidence.
Guide to Clinical Preventive Services, Third Edition: Periodic Updates, 2000-2003. Agency for Healthcare
Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/ratings.htm
4
Enquiry
Study about NFP practise during the last 10 years
in The Netherlands
drs. R. van Steinvoorn
Enquiry
User Profile and satisfaction
with the sympto-thermal method
•
database of 480 users
•
electronic enquiry send by email
•
20 questions about personal information and situation,
fertility, day-to-day use and user satisfaction
of the sympto-thermal method NFP
•
response of 246 (= 51% of total enquiries)
bestuurslid NFP-Nederland
FA-NFP Conference Antwerp 2008
note: average age of male = 31, average age of female = 29, with average
of ~ 2 children/couple before starting NFP against ~ 3 children/couple at
the moment.
Educational level
Civil status
User profile
User profile
Age distribution
NFP fits in a monogamous and stable relationship.
note: most of the singles follow the NFP course just before marriage!
Motivation for use of NFP
User profile
(mentioned by proportion of respondents,
more options possible)
Religion / View of life
Side effects of other methods
Health reasons
Reliability
Ecological reasons
65 %
49 %
22 %
20 %
6%
Other (incl. child-wish)
16 %
Wong: User profile
1
General use of NFP
note: 63% of the contraceptive pill users indicate that (hormonal) sideeffects are the main reason to switch to NFP.
NFP use
Motivations
Contraceptive history
Lifespan use of NFP
Reasons of drop-out
note: about 65% of the
drop-outs indicate to
use or to think about
using NFP again in the
near future!
9%
note: drop-out percentage after 1 year is 9%, and 36% in 10 years. 50% of
drop-outs occur in the first 3 years of use.
The real drop-outs
come from the
categories:
NFP use
NFP use
36 %
• menopause (100%)
• medical reasons
(75%)
• dissatisfaction (45%),
with average use of
3.8 years (!)
Efficacy of NFP
User failures of NFP
•
user Pearl index: 3.0 (1.8-2.6)*
•
method Pearl index: 0.38 (0.4-0.6)*
•
about 80% of the couples is still positive to very positive about NFP after
unintended pregnancy
* Advances in Contraception, 15 (1999), 69-83.
NFP use
NFP use
Efficacy data taken from our database:
note: Use of extra contraceptives during fertile days is low, resulting in
unintended pregnancies because of (fully aware) not keeping NFP rules!
Wong: User profile
2
Trying to conceive…
User satisfaction
12 cases
• 5 x positive after using NFP
Parallel consultation of gynaecologist/doctor occurred
Pregnancy occurred after 5, 12, 13 and 24 cycles without medical intervention
•
3 x positive after medical treatment (IUI, IVF)
•
4 x negative (‘not yet’)
Indication: NFP is a serious option, helpful for couples
Satisfaction
(In)fertility
Child-wish (primary)
8.45
(scale 1 -10)
•
Additional value of NFP-course (instead of do-it-yourself):
none
2%
little
7%
fairly much
28 %
much
37 %
very much
24 %
•
Overall-appreciation of NFP-method
positive – very positive
94%
Some comments…
‘Mede dankzij NFP heb ik mijn lichaam heel goed leren kennen, heeft de
relatie met mijn partner zich verdiept en heb ik leren omgaan met mijn
vruchtbaarheid’
Comments
‘Het is juist fijn om als man en vrouw samen om te gaan met de
vruchtbaarheid en hier samen een weg in te vinden.’
‘Therapeutisch voor het huwelijk. Je praat elke maand over seksualiteit.
Geen sleur!’
Study material and NFP consultant :
Some comments…
‘We raden het vooral stellen aan die van plan zijn te trouwen, het is een
hele goede voorbereiding op je huwelijk.’
•
‘NFP heeft een bijzondere invloed gehad op onze relatie. Het geeft veel
openingen tot gesprek onderling. NFP versterkt het zelfvertrouwen van
een vrouw.’
‘Wat een blijdschap dat we toch zonder medisch ingrijpen een kind hopen
te krijgen. Tijdens onze kinderwens-periode is er een aantal keren
contact geweest met de consulent van NFP. Deze gaf ons hele
waardevolle adviezen.’
Introduction
User Profile and Satisfaction with a
ST-NFP-method
in Flanders and the Netherlands
Roeline van Steinvoorn
Margreet Boender
Marie-Claire Van Wezenbeeck
Patrick Wong
80ies:
– Flanders: STM (Flynn) ObGyn Dr. Devos, Bruges
– Netherlands: STM (Rötzer) GP Dr. te Linteloo, The Hague
1990: change to STM According to German
Arbeitsgruppe (NFP-DAG)
Spreading NFP-DAG by accredited voluntary NFPteachers
Wong: User profile
3
Aim of the study
Materials and methods
Outline User profile
Track User satisfaction
Evaluate long term use
481 anamnesis charts of NFP-teachers 1990-2008
309 phone requests April-July 2008
men mean age: 33 (between 19 en 64)
women mean age : 31 (between 17 en 53)
Results (1)
Geografic spread
481 anamnesis data from clients
Unknown
2%
Not in List
1%
West Flanders
22%
Antwerp
41%
East Flanders
18%
Flemish Brabant
8%
Reason NFP-use
Limburg
8%
Number of children begin NFP use
250
200
Other
0%
Mean : 1.2
Unknown
20%
Effectiveness
2%
150
Religion
4%
Ecology
2%
100
Health
72%
50
0
0
1
2
3
4
5
6
Onbekend
Number of children
Wong: User profile
4
Marital status
Education woman
Unmarried
9%
Unknown
11%
Not in List
1%
Unknown
5%
Secundary school
19%
University
20%
Single
8%
Married
58%
Cohabitation
19%
Education man
Higher no university
50%
Results (2)
309 data from phone requests
Secundary school
20%
Unknown
21%
University
25%
Higher no university
34%
Reason to leave the method
Unknown
27%
Not in List
9%
Menopause
6%
No childwish,
sterilisation as
definitive option
18%
Would recommend the method
Not satisfied with
NFP and would not
recommend it at all
2%
Unknown
8%
Satisfied with
knowledge and
experience but
would not
recommend it to
others
2%
Too circuitous
15%
Medical reason
8%
Child wish
4%
End relationship
6%
Unplanned
pregnancy
6%
Satisfied with
knowledge and
experience and
would recommend it
to others
88%
Wong: User profile
5
Satisfaction with methodological
approach
Mean duration of use
120
Onbekend; 37
107
100
35
96
30
Mean number of years use who stopped (105): 3,5 years
Total mean (272): 4,9 years
25
80
70
20
60
15
40
10
5
20
d
jaa
r
en
ek
nb
jaa
r
jaa
r
O
18
17
16
jaa
r
jaa
r
jaa
r
15
14
jaa
r
12
13
ar
jaa
r
11
ar
jaa
r
ja
9
10
ar
ar
ja
ja
8
7
jaa
r
ja
6
5
ar
ar
ar
ja
10 op 10
ja
9.5 op 10
4
9 op 10
3
8.5 op 10
2
ar
8 op 10
ja
7.5 op 10
ja
7 op 10
1
6 op 10
0
5 op 10
jaa
r
0
0
Conclusions
Majority very satisfied with methodologic approach :
9/10
More than 88% would recommend the method
70% uses NFP because of health reasons
59% of men and 70% of women have higher
education
77% couples are maried or cohabit
21% stops because too circuitous or unplanned
pregnancy (mostly in first 2 years)
24% stops after several years because of menopauze
or accomplished childwish
General conclusion
The method as taught by NFP-Vlaanderen and NFPNederland has a great satisfaction.
There is need of a better follow up and support of NFP
users
Wong: User profile
6
AIMS
1. Know what easily accessible information about ‐ Natural Family Planning (NFP)
‐ Fertility Awareness Methods (FAM)
‐ and Lactational Amenorrhea Method (LAM)
are available in WHO Family Planning Cornerstone,
1. Is such a way of presenting things trust worthy? Soler F.
Lafollie P.
ACODIPLAN
1
Soler F. Lafollie P. ACODIPLAN Anvers 6/9/08 2
Family planning resources
WHO | Reproductive Health | HRP | What's new |
Publications | Contact | Search |
Evidence-based clinical and practical guidance
Year
2007
2006
2006
2006
2005
2004
2004
Title
Family planning - a global handbook for providers
Languages
en - es
Reproductive choices and family planning for people
living with HIV - Counselling tool
Essential medicines for reproductive health - guiding
principles for their inclusion on national medicines lists
The interagency list of essential medicines for
reproductive health
Decision-making tool for family planning clients and
providers (Power Point files)
Medical eligibility criteria for contraceptive use - 3rd
edition
Selected practice recommendations for contraceptive
use- 2nd edition
en
Family planning home page
en
p. 97
FAM = 2 p
en - fr
en - es - fr
ar - en – es
fr -pt - ru
ar - en – es fr
- ro - ru
6 LANGUAGES
Only Standard Days Method is offered as FAM !
170 p.
Evidence updates ...
ACODIPLAN Anvers 6/9/08 3
186 p (FAM = 3) (LAM = 1)
21 Power Point files
total: 244 pages
nº 19 LAM 6
nº 20 Fertility awareness 8
SYM & CAL A Accept C Caution
D Delay
6 LANGUAGES
ACODIPLAN Anvers 6/9/08 English, français, español.
5
Soler: WHO
1
Positive aspects
Presentation
17 Fertility awareness method
p. 239 ‐ 254 9 English, (Sept 2007)
9 Spanish, (Feb 2008)
9 Portuguese, (April 2008)
9 French, (May 2008)
9
9
9
9
9
9
9
9 Arabic,
9 Russian,
June 2008
9 Swahili,
9 Farsi,
9 Urdu,
9 Hindi
3 Previous cornerstones
http://www.who.int/reproductive‐
health/publications/dmt/index.htm
9
9
P. ACODIPLAN Anvers 6/9/08 7
Negative aspects 4)
9
9
Large place given to FAM
Health benefits (protect against risks of pregnancy)
Help women learn about their bodies and fertility
No side effects o health risks
Advanced education not required
No harm to men who abstain from sex
In general, abstaining during fertile times is more effective than using another method during fertile times.
Allow some couples to adhere to their religious or cultural norms about contraception
Can be used to identify fertile days by both women who want to become pregnant and women who want to avoid pregnancy
(…)
Withdrawal is not included
9 Pregnancy rates with consistent use are mentioned
9 Methods are divided into : Calendar based Methods
Symptoms based Methods
P. ACODIPLAN Anvers 6/9/08 8
Negative aspects 6)
Symptoms‐Based Methods (2007 p. 253)
COMPARING EFFECTIVENESS FP METHOD
2007
1967
?
ACODIPLAN Anvers 6/9/08 ?
Family Fertility Education
a resource package for teachers of Natural Family Planning Methods WHO 1982
Blat Centre for Health and Medical Education
9
p.93
Negative aspects 11)
How many A
in Calendar based methods
?
How many A
in Symptoms‐
based methods The most effective FAM (fertility awareness methods) are omitted in pages 325‐334
?
... and LAM
?
... and vasectomy ...
Negative aspects 12)
Soler: WHO
2
DISCUSSION (a)
DISCUSSION (b)
• After reading 3 other last WHO cornerstones, • The newest natural methods – some of them efficient – are explained in ‘WHO Family Planning – a global handbook for providers’ but:
9 One much efficient (but not so new) sympto‐thermal (double check) is omitted and
and
9 Information about others efficient FAM is incomplete or/and tergiversated
9 All FAM bundled together as ineffective methods. Soler F. Lafollie P. ACODIPLAN Anvers 6/9/08 13
• Decision‐making tool for family planning clients and providers
• Medical eligibility criteria for contraceptive us
• Selceted practice recommendations for contraceptive use
• it seems: 9 very difficult to propose and use FAM,
9 competent people in NFP and FAM were not consulted to write about those items, WHY?
9 published studies on FAM or NFP in scientific reviews are ignored by authors, WHY? 9 Previous WHO publications were more correct.
Conclusions (a)
Conclusions (b)
This congress could 1. formulate recommendations for future and better formulate recommendations versions of the Family Planning a global handbook for providers, evidence based‐guidance … A WHO family Planning Cornerstone
2. Propose an actualized presentation in Power Propose an actualized presentation Point and pdf of “Family Life Education, a package for teachers of Natural Family Planning Methods” published by WHO in English (1982) and French and Spanish in 1989 3. In “Decision making tool for family planning clients and providers” it is necessary to propose more FAM than Standard Days propose more FAM Method In particular the following need attention:
‐
‐
‐
‐
‐
chapter 17
chapter 18
appendix A
appendix B
and the back cover
Conclusions (c)
16
Conclusions (d)
4. Users obtain high effectiveness with NFP/FAM, if :
9 Objective data about all NFP/FAM are available,
9 Partners are motivated
9 and receive a correct training by experienced FAM teachers,
9 Male co‐responsability is encouraged
5. Other benefit of NFP/FAM is the safety
safety and
the women empowerment
women empowerment
ACODIPLAN Anvers 6/9/08 Soler F. Lafollie P. ACODIPLAN Anvers 6/9/08 Because people need to be given a very wide range of options in family planning methods, and no effective and no effective and safe method should be black‐
safe method should be black‐listed in WHO documents.
Thank you
17
Soler: WHO
3