This month, two of our BOMA board members, Eileen (the president) and Ann (the treasurer) had the opportunity to speak with Marc Sherman, the founder of Organic Conceptions.

After Marc and his wife struggled with infertility for years, he wanted to create a program that encompassed the whole person and was backed by research. The result was a life-changing program that can help couples struggling with infertility by meeting them where they are and helping them emotionally and psychologically. 
​
Check out our online video conversation with Marc to learn more about Organic Conceptions and see how BOMA providers can incorporate this program into their work.

Written by Sue Ek

When Abby Johnson’s life story hits the big screen on March 29, we want to support her by going to her movie, Unplanned. A former Planned Parenthood manager-turned-pro-life advocate and a Catholic convert, Abby is also a Billings Ovulation Method® teacher! A few years ago, she contacted me to schedule a Billings training in which she was going to invite friends (and pay for them). After a couple of emails, it occurred to me to ask, “Are you the Abby Johnson?” Sure enough, the famous Abby Johnson was so convinced of the importance of bringing the Billings Method™ to more women and couples that she personally organized and sponsored a training near her home in Texas. Abby continues to be a dues-paying member of BOMA and was even a banquet speaker for us a couple of years ago.

Recently, Abby sent us a trailer to her movie, along with a special shout-out to us. Please take a few minutes to watch the trailer. You won’t regret it!

Let’s help make Abby’s movie, Unplanned, a success in the box offices around the country! Besides watching the link, check out www.unplannedfilm.com for show times near you and for other details.

​BOMA is excited to announce that we are expanding! Craig Turczynski is our new Director of Development and Strategic Planning. We are interviewing Craig as our Spotlight Feature for this month so that all our membership can get to know him.
 
Q: Why don’t you start off by telling where you are from originally?

A: I was born in Chicago and lived in the suburbs until I was 12. My parents owned a couple of businesses and did well, but they wanted a slower, more wholesome lifestyle. So, they sold the businesses and bought a farm in rural northeast Iowa, where the closest town was 2 miles away and had only 2,000 people. I loved the farm life, working hard and being outside every day.

Q: What about your educational background?

A: I completed my BS in Animal Science at Iowa State University and then moved to Texas to pursue a graduate degree. In Texas, I met my wife, Rosa, got married, and started a family while completing my Ph.D. in Physiology of Reproduction at Texas A&M University. I then went on to do a postdoctoral fellowship in reproductive endocrinology at the Women’s Research Institute in Wichita, KS. There, I did basic research in reproductive endocrinology and was promoted to Associate Director of the assisted reproductive technology laboratory. In 1994, I accepted an Assistant Professor appointment in the Ob-Gyn department at LSUMC-Shreveport and helped build their infertility laboratory program.

Q: Tell us a little more about your time working in infertility. Did you struggle with the moral aspects of that work?

A: During the 5 years that I was the chief embryologist for the infertility program, I observed the difficulties couples experience when putting their faith in technology while trying to conceive. The cost, low success rate, and myriad of additional problems this conventional approach produces began to weigh heavily on my heart. Abandoned embryos, multiple pregnancies, selective reductions, frequent miscarriages, and then questions about genetic and physical abnormalities were just some of the consequences of this disordered approach. When my boss forced me to carry out the wishes of a patient and discard their “excess” embryos, I had a conversion. I left the field and took an offer to work for a friend in the orthopedic medical device field.

Q: That’s fascinating. What a conversion! What happened after that, and how did you end up as a Billings teacher?

A: For the next 20 years, I focused on earning a living in the medical device field, but missed working in the field of reproductive health. Fortunately, as a reproductive physiologist, I knew to stay away from hormonal birth control, and my wife and I used natural means to avoid and achieve pregnancy. I felt a calling to use my reproductive training and learn more about NFP. So in 2008, I completed the first phase of training of the Creighton model, and in 2018, I completed the correspondence course to become a BOM teacher. I am now completing my practicum under the tutelage of Martha Winn and learning how to incorporate nutrition into my teaching by taking courses in holistic nutrition. I believe the timing is providential and related to a need for me to put more trust in God.

Q: Can you tell us a little bit more about your wife and children?

A: My wife, Rosa, is originally from Guadalajara, Mexico. We met in San Antonio, have been married for 30 years, and we have 3 grown children. Seth is recently married and is a police officer in Dallas. Alexa is also married, and she and her husband have one son, Ronan, who is 10 months old. Alexa is a writer and has published two books. Daniel is finishing college in computer programming. We live on a small farm north of Dallas. Rosa runs our Menchie’s frozen yogurt franchise store, while I work full-time for a new start-up medical device company. We are active members at Holy Family Catholic Church in Van Alstyne.

Q: I’d like to hear more about your farming experience. Are you talking about vegetables, animals, or both? Is this just for your family, or do you also sell what you produce to others?

A: We have lived on the farm since 2000 and have always had a few cattle, a horse, cats, dogs, and a garden. We mostly homeschooled our children, and the farm was an important part of their life. A few things happened around 2014 that made us start farming with more intensity. I was displaced from my medical device job of 15 years due to a purchase and restructuring by Johnson & Johnson, and both Rosa & Seth were diagnosed with illnesses. So, we wanted to raise more of our own food for health reasons, and we needed to make the farm a real business for economic reasons. Our main products were grass-fed and pastured pork, beef, turkey, chicken, and eggs, but we also aspired to increase our vegetable production as well. We sold our products direct to consumers at farmers markets and home delivery, and we marketed via a website and blog www.countryworkforce.com.  In 2017, I went back to work for another medical device company, so we downsized and only produce for family and a small group of friends now.

Q: What are some of the first projects that you will be tackling as our new Director of Development and Strategic Planning?

A: Most importantly the organization needs to bring in revenue, which will allow us to have a much bigger impact. I will be working with Sue and the board to increase implementation of the services we are currently offering, such as teacher training and the medical seminar. I will be helping to drive awareness at medical conferences and health professional events. I will also be working on key strategic initiatives that promote the use of the BOM with the practice of individualized medicine, especially in regards to reproductive health, infertility, and the perimenopausal transition.

Q: Overall, what is your vision for the future of BOMA?

A: My vision is to grow the capabilities and efficiencies of the organization with a larger budget and a staff of people who focus their time on the individual services we provide. My dream is to see a more widespread acceptance and implementation of fertility awareness methods in the medical and patient community. I believe that the Billings Ovulation Method® has the scientific validation and the simple, natural approach needed to lead this charge. The Billings Ovulation Method® can be coupled with nutritional and lifestyle assessment as an effective means to assist with reproductive health issues without any of the complications associated with conventional technology. I am excited to join the team of teachers, religious, professionals, and laity committed to the application and promotion of the Billings Ovulation Method®. It is through our collective passion for this worthy cause that we can realize the dream of thousands of women and couples experiencing a more natural and healthy reproductive life.

Jennifer Quigley, DNP, RN, FNP-BC 
Erin Shankel, DNP, RN, FNP-BC 
Linda Wofford, DNP, RN, CPNP   
 
Perceptions of Natural Family Planning Among Health Providers: A Systematic Review 

Preventing unintended pregnancies in females of childbearing age is a major topic of global and domestic importance, having a substantial impact on maternal and newborn mortality, morbidity, and the economy. In 2013, almost 290,000 maternal deaths occurred due to complications of pregnancy or child-birth, 99% of which were in underdeveloped countries. 1 Infant mortality is just as devastating with 4.6 million deaths before the age of one year, a large number being attributed to multiple factors related to unhealthy timing of pregnancy. 2 The World Health Organization 2 continues to state that the ability of women to adequately control the timing and spacing of pregnancy can dramatically decrease maternal mortality due to pregnancy complications and unsafe abortions, decrease infant mortality, prevent the spread of HIV to infant populations, and reduce adolescent pregnancy. Reducing unintended pregnancy is a focus of both the 2015 United Nations Millennial Development Goals3  and the United States Healthy People 2020 objectives.4

A study by Finer, Zolna 5 indicated that in 2008 in the U.S., 51% of pregnancies were unintended at the time of conception, increasing 3% from 2001 despite advances in contraception. Because of this continued increase, The Healthy People 2020 initiative 4 includes objectives to decrease the rate of unintended pregnancies in the U. S. by 10% before the year 2020. Several of the interventions for this initiative consist of increasing publicaly funded clinics that offer contraception, expanding sexual and reproductive health education, and increasing the use of contraceptives and barrier methods in adolescents.4 However, Jones, Mosher, Daniels 6 reported that in 2010, out of 61.7 million women of childbearing age in the U.S, only 7% were sexually active and not using any method of contraception. One major contributing factor for unintended pregnancies among natural or artificial contraceptive users is failure to use the method correctly, which includes inconsistent application, abandonment, or drug interactions. 7 Studies report that the most common reason for discontinuation or inconsistent use of hormonal or artificial contraceptives is the presence or fear of side-effects, including but not limited to breast cancer, cervical cancer, liver cancer, weight gain, myocardial infarction, stroke, hyperlipidemia, hypertension, ocular lesions, gallbladder disease, and bleeding irregularities. 8-17

While current initiatives to prevent unintended pregnancy are focused toward increasing modern hormonal or artificial contraception, many women either cannot or will not partake in these methods due to adverse effects, unwanted side effects, religious affiliation, cost, or personal preference. It is important that providers offer culturally competent and individualistic care for these women and still meet the need to prevent unintended pregnancy.   

The past 40 years have seen major scientific advancements in fertility awareness methods of family planning. Specific markers of fertility have been discovered that, when observed, allow a woman to effectively recognize her time of fertility. 18 Studies by Alliende, Cabezón, Figueroa, and Kottmann,19 Fehring, 20 and Hilgers 21 determined that detectible cervical fluid changes and basal temperature spikes correlate with exact days of ovulation in 95-98% of cycles as determined by comparison with medical identification of ovulatory phases, such as ultrasound and hormonal detection either through urine samples or blood testing. Research and development around these markers has sparked development of several methods, which will be hereby referred to as modern methods of natural family planning (NFP) including the Billings Ovulation Method, the Creighton Model, basal body temperature (BBT), and the symptothermal method. The Billings Ovulation Method and the Creighton Model both rely on observable cervical mucus changes to detect fertility, whereas BBT relies upon the spike of body temperature that occurs with ovulation. The symptothermal method uses a combination of both of these approaches. Each of these methods has been shown to have evidence-based use-efficacy of preventing pregnancy of 98.8-99.4%. 22,23 A newer addition to modern methods of NFP that is gaining popularity is the StandardDays© method, a method developed from the calendar/rhythm method that involves more specific calculation of ovulation days, but does not use any observational markers. 24 This method has also been shown to have a 95% efficacy rate of preventing pregnancy. 25 

Modern methods of NFP have been shown to be equally as effective as hormonal contraceptives in preventing pregnancy; yet only 0.7% of women use these methods. 7 Pallone, Bergus 26 suggest that health care providers’ aversion to these methods could contribute to the lack of use in society. Therefore, an integrative review was conducted to determine the state of the literature on current North American health care providers’ attitudes toward or knowledge of fertility awareness based methods to prevent pregnancy.

SEARCH METHODS 

An exhaustive search of literature from 2009 to 2014 was conducted using various combinations of: attitudes, barriers, knowledge, natural family planning, fertility awareness, and ovulation method. Search engines included CINAHL Complete, MEDLINE Complete, PsycARTICLES, SocINDEX with Full Text, PsycINFO, and Religion and Philosophy Collection in order to capture studies from various disciplines. The authors limited the search to peer reviewed, primary research articles in the English language.   

RESULTS 

The initial search from the databases returned 338 results. The authors removed duplicate articles, any articles not conducted in North America, and those that were not relevant to the health care field, i.e. natural disaster, farming, and natural resources, leaving 36 articles. A preliminary scan of the titles and abstracts excluded an additional 16 articles that were irrelevant to natural or fertility-based family planning methods to prevent pregnancy, such as surrogate usage, family conferences, infertility, cancer quality of life, childhood obesity, pain sensation related to the menstrual phase, elderly quality of life, early pregnancy recognition, menstrual cycle and respiratory symptoms, abortion, and fertility preservation in cancer. Using the 20 remaining articles, a more thorough abstract review was conducted to include primary studies only pertaining to health care providers’, physicians’, or clinicians’ attitude, knowledge, barriers to, or perception of natural or fertility awareness based methods of family planning. This abstract screening process yielded three articles for this review. Sources referenced by the three included articles were then scanned for unique studies matching the inclusion criteria. Three additional studies matched the inclusion criteria, but were older than the authors’ original five-year time frame. However, these studies were included to further enhance knowledge of the subject matter. Figure 1 depicts the publication selection process.

FINDINGS

During the review process, the authors were able to distinguish four categories that emerged from the literature in respect to providers’ knowledge of NFP and application to practice: Amount of NFP education, perceptions of effectiveness, availability of resources, and religious or moral allegiances. These four categories emerged as the articles were analyzed for commonalities and distinguishing factors through noting patterns, clustering, and seeing plausibility.  The 6 selected articles’ quality were evaluated for authenticity, methodological quality and information value.  The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) was adapted for non-internet surveys and used to evaluate the 6 articles.27 The adapted checklist can be found in the Appendix. The findings can potentially impact policies and education programs of health care providers, including physicians and nurses, to add valuable NFP education in order to provide individualized care to all women of childbearing age who wish to prevent or postpone pregnancy. 

AMOUNT OF NFP EDUCATION

The first extrapolated category determines that providers are not adequately educated in modern methods of NFP (Table 1). Three of the six analyzed studies revealed that deficient education in modern methods of NFP is a common theme contributing to health care providers aversion from NFP as an option to prevent pregnancy.28, 29, 30 The study by Fehring28 showed that limited time frame of less than one hour total, if any, was spent on NFP instruction in basic medical and nursing education. Stanford, Thurman, Lemaire 30 found that providers who had further education in modern methods of NFP, were aware of, and/or worked with qualified NFP instructors were more likely to view NFP as a reliable method for prevention of pregnancy and offer modern methods to qualifying patients. Fehring, Hanson, and Stanford 29 substantiated this trend in deficient education when they found that certified nurse midwives (CNMs), who had more education in modern methods of NFP were more likely than physicians to offer it to women as an option to prevent pregnancy. However, CNMs still reported less than adequate levels of comfort and preparation to recommend this form of natural contraception to patients. 

PERCEPTIONS OF EFFECTIVENESS

The second category was expressed in five studies that explored providers’ knowledge of modern methods of NFP. Each of the five studies showed that the providers had significantly lower perceptions of effectiveness than what has been reported in the literature (Table 2). Approximately 90% of 2,300 health care providers underestimated the effectiveness of modern methods of NFP as much as 30%, although CNMs and physicians who worked with local instructors reported more accurate estimates of effectiveness. 28, 32

AVAILABILITY OF RESOURCES

Two studies showed that lack of time to teach and availability of NFP information are contributing factors for providers’ aversion of NFP to prevent pregnancy (Table 3). In order for NFP to be most effective, motivated clients need qualified instructors with ample time to teach the method of choice and to follow up with the client to ensure understanding. 33 Kelly, Witt, McEvers, Enriquez, Abshier, Vasquez, and McGee 34 found that Title X funded clinics, who serve a population that could benefit greatly from NFP, have very little time to spend teaching these clients any method of NFP, and have a lack of education materials or instructor resources to provide additional information to potential candidates. Another reviewed study by Stanford, Thurman, Lemaire 30 found providers who had and were aware of qualified NFP instructors in the same zip code had more information available to them and were more likely to view NFP as a viable option to family planning. They were also more likely to refer women to receive instruction in an NFP method to prevent pregnancy.30

RELIGIOUS/MORAL ALLEGIANCES

The last category derived from the analysis is the effect of religious and/ or moral allegiances of providers toward providing NFP (Table 4). Lawrence, Rasinski, Yoon, Curlin 32 and Choi, Chan, Wiebe 31 found that religious beliefs in general were a significant determinant of whether or not the provider viewed NFP as a viable option for most women. However, there were no statistically significant differences among religions, so long as the beliefs were held in high regard and considered important to uphold in practice. 31,32

DISCUSSION 

From reviewing the current literature, suggested barriers to effective implementation of modern methods of NFP from the health care provider standpoint include amount of NFP education, perceptions of effectiveness, availability of resources, and religious/ moral views. While the literature suggests these barriers, it could be possible that the categories may be correlated. For example, lack of education can lead to lack of familiarity with modern methods of NFP, which could contribute to inaccurate efficacy perceptions, whereas religious and moral allegiances could hold strong guidance in the provider’s decision to find resources in order to offer NFP as an alternative to hormonal or other artificial forms of contraception. A study by Gribble, Lundgren, Velasquez, Anastasi 35 showed that educating health care providers in modern NFP methods significantly decreased provider bias, improved attitudes, and increased presentation of NFP in contraceptive consultations as a viable method to prevent pregnancy. Gribble, Lundgren, Velasquez, and Anastasi 35 also reported an increase in informed decision and client selection of NFP when the providers were more educated and comfortable with NFP. This review can act as a basis of understanding to develop and integrate an education curriculum into nursing and medical education, so that providers feel more comfortable prescribing and teaching modern methods of NFP to their patient population as an evidence-based, effective, culturally accepted, and natural way to prevent or post-pone pregnancy.  
 
Another implication of this review could be to create and promote policies that enhance resources available to health care providers. By having education material, time-efficient teaching strategies, and possibly increase the number of qualified instructors, more providers may be able to offer modern methods of NFP and help decrease the gap of people who are currently at risk for pregnancy due to refusal or inability to take current modern hormonal or artificial contraceptives. Policy updates in nursing and medical education programs also could help integrate the above mentioned education programs for better familiarity of NFP methods. 

This review suggests that more research should be performed in understanding provider viewpoints, as well as interventions that can help overcome these barriers. Another research topic suggested by the review is determining if a standardized policy-implemented education program would create provider familiarity in modern methods of NFP so that effective prevention of unintended pregnancy can be provided to a more diverse population. 

LIMITATIONS

A limitation of this review is the scarce amount of research on clinician perceptions of NFP. No randomized controlled-trials were available to review, which could depreciate the value of the findings. Also, of the limited amount of studies that were available, many were authored or co-authored by the same people, potentially monopolizing the review.

CONCLUSION

With unintended pregnancy still on the rise in the United States, it is essential that providers offer reliable, safe, and evidence-based effective ways to prevent unintended pregnancy. While modern hormonal and artificial contraception is the current, most advertised way to prevent unintended pregnancy and ensure healthy timing and spacing of pregnancies, not all women can or will partake in these methods. Culturally accepted effective methods should be offered by all providers to ensure every woman has the ability to adequately postpone or space pregnancies. The purpose of the integrative review was to provide context into the perceptions, knowledge, and potential barriers to providing evidence-based effective modern methods of NFP of health care providers in North America. Through this review, four themes emerged that can provide a basis of understanding provider barriers on which to begin a framework that guides integration of modern methods of NFP into the contraception discussion between providers and clients; amount of NFP education, perceptions of efficacy, availability of resources, and religious/moral allegiances. Identifying the gaps in education and resources available to providers allows for the implementation of policies and education programs to enhance greater knowledge and allow NFP to reach a broader population of users.  
 

REFERENCES
 
1. World Health Organization. Maternal mortality: Fact sheet N°348. 2014.
2. World Health Organization. Family planning: Fact sheet N°351 2012.
3. United Nations. Millennium development goals and beyond 2015. 2014.
4. U.S. Department of Health and Human Services. Healthy people 2020: Family planning. 2014.
5. Finer LB, Zolna MR. Shifts in intended and unintended pregnancies in the united states, 2001-2008. American Journal of Public Health. 2014;104(S1):S43-S48.
6. Jones J, Mosher W, Daniels K. Current contraceptive use in the United States, 20062010, and changes in patterns of use since 1995. National Health Statistics Reports. 2012(60):1-25.
7. Guttmacher Institute. Contraceptive use in the United States. 2014.
8. Bayer HealthCare Pharmaceuticals Inc. Highlights of health prescribing information. 2012.
9. Janssen Pharmaceuticals Inc. Ortho Tri-Cyclen Lo tablets prescribing information. Titusville, New Jersey: Janssen Pharmaceuticals, Inc; 2014.
10. World Health Organization. Combined hormonal contraceptives and venous thromboembolism. WHO Drug Information. 2014;28(1):21.
11. Gourbil M, Grandvuillemin A, Beyens M-N, et al. Thromboembolic events in women exposed to hormonal contraception or cyproterone acetate in 2012: A cross-sectional observational study in 30 french public hospitals. Drug Safety. 2014;37(4):269-282.
​12. Haarala A, Eklund C, Pessi T, et al. Use of combined oral contraceptives alters metabolic determinants and genetic regulation of C-reactive protein. The Cardiovascular Risk in Young Finns Study. Scandinavian Journal of Clinical & Laboratory Investigation. 2009;69(2):168-174.
13. Josse AR, Garcia-Bailo B, Fischer K, El-Sohemy A, Khan RH. Novel effects of hormonal contraceptive use on the plasma proteome. PLoS ONE. 2012;7(9):1-10. 
14. Soska V, Fiala J, Nebeska K, Jarkovsky J, Hruba D. The atherogenic index of plasma is increased by hormonal contraception. Scandinavian Journal of Clinical & Laboratory Investigation. 2011;71(2):94-100.
15. Brunner Huber LR, Hogue CJ, Stein AD, et al. Contraceptive use and discontinuation: Findings from the contraceptive history, initiation, and choice study. American Journal of Obstetrics and Gynecology. 2006;194(5):1290-1295.
16. Moreau C, Cleland K, Trussell J. Contraceptive discontinuation attributed to method dissatisfaction in the United States. Contraception. 2007;76(4):267-272.
17. International Agency for Research on Cancer. Monographs on the evaluation of carcinogenic risks to humans: Combined estrogen−progestogen contraceptives and combined estrogen− progestogen menopausal therapy. Vol 91. Lyons, France: International Agency for Research on Cancer; 2007.
18. Bo C, Dunson DB, Stanford JB. Dynamic model for multivariate markers of fecundability. Biometrics. 2010;66(3):905-913.
19. Alliende ME, Cabezón C, Figueroa H, Kottmann C. Cervicovaginal fluid changes to detect ovulation accurately. American Journal of Obstetrics & Gynecology. 2005;193(1):71-75.
20. Fehring RJ. Accuracy of the peak day of cervical mucus as a biological marker of fertility. Contraception. 2002;66(4):231-235.
21. Hilgers TW. Natural family planning. I. The peak symptom and estimated time of ovulation. Obstetrics and gynecology (New York. 1953). 1978;52(5):575.
22. Fehring RJ, Lawrence D, Philpot C. Use effectiveness of the Creighton model ovulation method of natural family planning. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing. 1994;23(4):303-309.
23. Frank-Herrmann P, Heil J, Gnoth C, et al. The effectiveness of a fertility awareness based method to avoid pregnancy in relation to a couple's sexual behaviour during the fertile time: a prospective longitudinal study. Human Reproduction (Oxford, England). 2007;22(5):1310-1319.
24. Arévalo M, Yeager B, Sinai I, Panfichi R, Jennings V. Adding the Standard Days Method® to the contraceptive method mix in a high-prevalence setting in Peru. Rev Panam Salud Publica. 2010;28(2):80-85. 
25. Arèvalo M, Jennings V, Sinai I. Efficacy of a new method of family planning: the Standard Days Method. Contraception. 2002;65:333-338.
26. Pallone SR, Bergus GR. Fertility awareness-based methods: another option for family planning. Journal of the American Board of Family Medicine. 2009;22(2):147-157.
27.  Eysenbach G. Improving the quality of web surveys: The checklist for reporting results of internet e-surveys (cherries). Journal of Medical Internet Research. 2004;6(3)e34. doi:10.2196/jmir.6.3.e34
28. Fehring R. Physician and nurses' knowledge and use of natural family planning. The Linacre Quarterly. 1995;62(4):22-28.
29. Fehring RJ, Hanson L, Stanford JB. Nurse-midwives' knowledge and promotion of lactational amenorrhea and other natural family-planning methods for child spacing. Journal of Midwifery & Women's Health. 2001;46(2):68-73.
30. Stanford JB, Thurman PB, Lemaire JC. Physicians' knowledge and practices regarding natural family planning. Obstetrics And Gynecology. 1999;94(5 Pt 1):672-678.
31. Choi J, Chan S, Wiebe E. Natural family planning: physicians' knowledge, attitudes, and practice. Journal Of Obstetrics And Gynaecology Canada: JOGC. 2010;32(7):673-678.
32. Lawrence RE, Rasinski KA, Yoon JD, Curlin FA. Obstetrician-gynecologists' views on contraception and natural family planning: a national survey. American Journal of Obstetrics & Gynecology. 2011;204(2):124.e121-127.
33. Fehring RJ. Influence of Motivation on the Efficacy of Natural Family Planning. MCN, the American journal of maternal child nursing. 2013;38(6):352.
34. Kelly PJ, Witt J, McEvers K, et al. Clinician perceptions of providing natural family planning methods in title X funded clinics. Journal of Midwifery & Women's Health. 2012;57(1):35-42.
35. Gribble JN, Lundgren RI, Velasquez C, Anastasi EE. Being strategic about contraceptive introduction: the experience of the Standard Days Method®. Contraception. 2008​;77(3):147-154.

​J Integrative Review 4.29.16

During these winter months when many of us find getting enough natural Vitamin D through sunlight difficult at best, we are pleased to share this interesting case study of how a woman in Malaysia successfully achieved a much-desired pregnancy after her Vitamin D levels were discovered to be too low. Dr. Lek-Lim Chan, an Associate Director of WOOMB International and the President of Natural Fertility Awareness Service of Malaysia, has spoken at a few of our BOMA-USA conferences and received great reviews.

​by Dr. Lek-Lim Chan
 
Note: Permission has been granted by client to share this case study.
 
Case History & Background – This case was first referred in October 2012 by a Billings Ovulation Method® (BOM) teacher from Kuala Lumpur. The client was aged 31, married 6 years trying to conceive unsuccessfully. She had just learned BOM charting in July 2012.
 
Weight 46 kg; height 161 cm; waist 26 inch = 66 cm BMI=17.75
​
Maternal grandmother had diabetes for perhaps 15 years before she died aged 85. She was only on medication.
 
She said Vitamin D was tested in April 2012 and was well below normal, although she was not able to find her report.

She had seen a gynecologist in August 2012 who tested her female hormones and found her FSH to be “unreasonably high”. She was then told she may reach menopause in 2 years.
 
Author first met her on 8 November 2012. Her charts showed regular bleeds with follicular development, but no Peaks. This means there is follicular activity probably not reaching ovulation although there is some ovarian activity. (See chart below)

Chart of 7 July 2012 – 5 January 2013 is as follows (with a gap between 20 September and 17 November):

​The following tests were done on 24 November 2012:
​
Glucose

Note: At that time, author only did 2-point test for insulin to save money for patient. Now he is convinced that the full 5-point test as devised by Prof. Pilar Vigil must be done to ascertain for sure if the woman is insulin resistant. Sometimes, any one of the 5 readings can exceed Prof. Pilar’s reference range, already indicating insulin resistance.
 
The only abnormal reading was Vitamin D with a slight elevation of testosterone above Pilar’s limit.
 
The woman commenced Cholecalciferol (Vitamin D3) 1000 IU twice per day - one in morning and one in evening. Started in January 2013.
 
The next chart (5 April – 3 June 2013) shows she has reached Peak. However, not every bleed cycle has a Peak.
​
Chart of 5 April – 3 June 2013:

A Peak occurred on 17 April 2013, but there was no pregnancy although intercourse occurred on Peak day. However, there was no Peak in the next bleed cycle.
 
Author advised her to consider retesting the Vitamin D level. She hesitated. But on 4 pm, 21 Nov 2013, an SMS was received:

I used a home pregnancy kit yesterday, and it came out positive. Haven’t gone to the doctor to confirm result yet.
 
Chart of 24 Sep – 19 Nov 2013, during which pregnancy achieved:

She identified a Peak with only 2 days development on 6 October 2013; there was intercourse but no pregnancy. Then, she identified 4 November as a day of extreme slipperiness and therefore a day of very high fertility. But a Peak cannot be identified because there was no changing developing pattern. That does not mean there was no ovulation. It is just that ovulation cannot be confirmed if there is no Peak. And the one intercourse on this very slippery day without a Peak resulted in pregnancy.
 
Ultrasound scanning later estimated the date of conception as 5 November 2013, thus confirming that she did ovulate on or around that very slippery day.

Author then advised her to recheck her Vitamin D and testosterone, and her results were:

Vitamin D was then well within normal range, and testosterone had dropped slightly from 2.0 nmol/L to 1.9 nmol/L.
 
She continued with Vitamin D supplementation throughout pregnancy, and the baby girl was born on 25 July 2014.

Baby girl at birth

Girl at age 1

Summary by Heather Turner

Pregnancies, especially unintended pregnancies, have a substantial impact on the economy as well as maternal and newborn health. Preventing unintended pregnancies is therefore a topic of global importance. The ability of women to control the timing of pregnancy can decrease infant and maternal mortality from pregnancy complications and abortions, prevent the spread of HIV to infant populations, and reduce adolescent pregnancy. The vast majority of women of childbearing age who are sexually active are using contraception and yet are still experiencing surprise pregnancies.
 
At the same time, many women either cannot or will not use these methods because of adverse effects, religious affiliation, cost, or personal preference. It is important for providers to offer culturally competent and individualized care for these women, while still meeting the need to prevent unintended pregnancies.
 
The past 40 years have seen major scientific advancements in fertility awareness methods of family planning. Modern methods of NFP have been shown to be as effective as hormonal contraceptives in preventing pregnancy, but only 0.7% of women use these methods. Past studies suggest that health care providers’ aversion to these methods could contribute to the lack of use in society. Therefore, Quigley and fellow authors did a thorough review of existing literature among North American health care providers to learn more about their knowledge of and attitudes toward NFP.
 
 
Findings
 
There are four factors that seem to determine providers’ knowledge of NFP and application to their medical practice: amount of NFP education, perceptions of effectiveness, availability of resources, and religious or moral allegiances.
 
Amount of NFP Education
Providers are not adequately educated in modern methods of NFP, leading to an aversion to NFP as an option to prevent pregnancy. One hour total, if any, was spent on NFP instruction in basic medical and nursing education. However, providers who had further education in modern methods of NFP, were aware of, and/or worked with qualified NFP instructors were more likely to view NFP as a reliable method for prevention of pregnancy and offer modern methods to qualifying patients.
 
Perceptions of Effectiveness
Providers had significantly lower perceptions of effectiveness than what has been reported in effectiveness studies. In one study, approximately 90% of health care providers significantly underestimated the effectiveness of modern methods of NFP. Certified nurse-midwives and physicians who worked with local instructors reported more accurate estimates of effectiveness.
 
Availability of Resources
Many providers do not have the time either to learn NFP themselves or to teach it to their patients. In order for NFP to be most effective, motivated clients need qualified instructors with ample time to teach the method of choice and to follow up with the client to ensure understanding. Title X funded clinics, which serve a population that could benefit greatly from NFP, have very little time to spend teaching these clients any method of NFP. They also do not have educational materials or instructor resources to provide additional information to potential candidates. Providers who had and were aware of qualified NFP instructors in the same ZIP code had more information available to them and were more likely to view NFP as a viable option to family planning. They were also more likely to refer women to receive instruction in an NFP method to prevent pregnancy.
 
Religious/ Moral Allegiances
Religious beliefs in general were a significant determinant of whether or not the provider viewed NFP as a viable option for most women. However, there were no statistically significant differences among religions, so long as the beliefs were held in high regard and considered important to uphold in practice.
 
Message for Instructors and Promoters of Billings
 
As instructors, Quigley’s study of health care providers and NFP attitudes can help spur us toward smart ways to increase NFP knowledge in the medical providers in our area. If we can offer providers educational material and time-efficient teaching strategies and if we can increase the number of qualified instructors in our area, more providers may be able to offer their patients modern methods of NFP. This increase in the use of NFP will help decrease the group of people who are currently at risk for pregnancy due to refusal or inability to use artificial contraceptives. We can also do our part to encourage policy updates in nursing and medical education programs for better familiarity with NFP methods.

To read Jennifer Quigley's full article, click HERE

J Integrative Review 4.29.16
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Q.     When did you first hear about the Billings Method, and what inspired you to teach it?

We started our marriage in 1981 with another method, and it was quite some time before I heard about the Billings Ovulation Method®. I was searching for an accurate method based on science. Life is busy! The simplicity of the method was a real plus.

 Q.     You were perhaps the first teacher in the United States to become trained through WOOMB’s Correspondence Course. Now, as Education Chair for BOMA-USA, what are your thoughts on that specific format?

The Correspondence Course met my needs. The course was not offered yet through BOMA-USA so I completed the course through WOOMB. All communication was through “snail” mail. I anxiously awaited the return of my work every month. My trainer was Pauline Feehan, developer of the course. Her feedback was effective. The material progressed in an organized manner, so I was able to absorb the concepts accurately.  A real emphasis was placed on the goal of teaching the authentic Billings Ovulation Method®. Eventually I completed the work, as well as my case studies, and was certified. I felt completely supported throughout the process. Shortly after I completed the course through Australia, BOMA-USA began to offer the curriculum.  The course is conducted through email and is augmented with PowerPoint presentations. I frequently video-conference with my Trainees to provide additional support and teaching. I highly recommend this platform as a choice for individuals. 

Q.     It seems your life choices, both as a registered nurse and as a mother who homeschooled all of her children through high school, were providential stepping stones to your work with us, particularly as Education Chair.  Tell us how those two roles have been useful for your work with us.

The lifelong role of any nurse is to foster healthy lifestyles in others and to educate. Whether one is in the clinical area or using the principles in the family and community, nursing skills are valuable. I worked in cardiovascular recovery, pediatrics, postpartum, and was a breastfeeding educator. I have always been interested in preventive medicine and healthy lifestyles. Most nurses are familiar with the experience of others asking for explanation of medical concepts and being a knowledgeable resource. I think nurses are in a good position to educate and suggest referral if needed. As Education Chair, I use many of these skills listening and meeting the needs of the clients, Trainees, and Certified Teachers. The EC functions to ensure the authentic Billings Ovulation Method® is taught and communicated to others. Communication with the medical community is helpful with a background in nursing.

We homeschooled all four of our children through high school. We recently celebrated finishing 29 consecutive years of homeschooling with a trip to Rome with our daughter Christy. The amount of networking and collaboration done with others to accomplish this goal was enormous. I taught classes at the homeschool learning cooperative when asked. Our family began the first homeschool basketball team in our community. Years later it is thriving and has grown to 5 teams. Our family participated in many other pursuits, as do most families. Parents are always rolling up their sleeves to help, and we were no different. These experiences taught me how to nurture a group project.  Life is full of opportunities to “stretch” and grow for all of us.

Q.     How can we motivate inactive teachers to begin again? 

If inactive teachers are waiting for an invitation to resume, consider this to be just that! We need you. Cultural trends are emphasizing a more holistic approach. You can make a difference in your community. Pull out the materials from your Teacher Training and begin to review. Start with the story of Drs. John and Evelyn Billings. Remember why you were called to teach. I think one of the advantages to teaching the Billings Ovulation Method® is the solid research and science which is the foundation. Look at the curriculum and remember your fascination when you first learned. Someone in your family, your church, your community wants to know this good news. Get in touch with the Education Committee and talk to us. We can help you with renewal of certification. Fr. Joseph Hattie, spiritual director of WOOMB, provides material which inspires those who teach, as does Fr. Daniel McCaffrey, spiritual director of BOMA-USA. Everyone has “seasons” in life. Perhaps you are being called to begin again. We are here for you!

Q.      How often does the Education Committee meet, and what are some of your goals this year?

We have an excellent group on the Education Committee. I am joined by talented individuals. We are continuing our quarterly webinars. These are designed to keep everyone connected and have continuing education. One of our members, Dr. Montserrat Ayala-Ramirez, is heading up a Focus Group Research Project. She completed the CITI Program Course through the University of North Carolina and will beginning soon. Our Medical Seminar for nurses and physicians occurs in May (https://www.boma-usa.org/medical-seminar.html). Continuing Medical Education (CMEs) and Continuing Nursing Education (CNUs) credits will be awarded for this live online event. It is a good opportunity for BOMA-USA Teachers and Members to get the word out to providers. In the fall we are planning an Extension Course. The course is a valuable component of ongoing education. Difficult charts are studied along with an in-depth look at the Billings Ovulation Method® and Prof. Brown’s studies on the Continuum.  Of course, Teacher Trainings and Practicum Supervision are always front and center.

 Q.     Tell us about the presentation you will be giving during the next Catholic Medical Association conference in September.

I will be giving a talk at the Catholic Medical Association (CMA) Conference in Nashville, TN titled, “Fertility Awareness Management Education in Medical Practices; Empowering Patients to Participate in Care, Simplifying the Office Visit”. I have received wonderful feedback from a survey sent to providers about the topic. The theme of the conference is “Physician, Heal Thyself”. I cannot say enough good things about the CMA and the work the organization does. Local communities can form CMA Guilds for support and education among the medical community. We are prayerfully forming a Guild in my diocese. BOMA-USA will have a table of information at the conference.

Q.      What about your family? Tell us about them.
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I am married to Earl. He is a professional baseball scout with the MN Twins. He is my support and strength, often accompanying me when I give talks. I am sure many of the Teachers can say this about their spouse. We have 3 grown and married sons and a daughter in college. Our six grandchildren are a joy, and we love grandparenting!  One of our sons and his wife were asked recently to give a witness talk about their marriage during a Mass for married couples. How humbling it was to hear them thank us for being a good example. I pray we continue to provide a good example. Our parish priest said in his homily that marriage is one of the best evangelization tools. Drs. John and Evelyn Billings reminded teachers of the method that they are teaching a “lifestyle.” I believe this is true. It is a lifestyle of love. 

Extensive research has shown that sex hormones, particularly estrogen and progesterone, impact women's lives in a significant way. From menarche to menopause, and through all the stages in between, women experience dramatic fluctuations in the levels of sex hormones. These fluctuations are part of the ovarian continuum - the various types of ovarian activity that a woman can present throughout her lifetime - and they affect the body as a whole, including the central nervous system (CNS).
Steroid hormones, also known as “neurosteroids” or “neuroactive steroids” because they have an effect in the CNS and/or the PNS (peripheral nervous system), are produced in peripheral glands, in adipose tissue, and in the brain (by neurons and glial cells). Both in the CNS and in peripheral tissues, estrogen and progesterone act via the classical pathway by binding to steroid intracellular receptors that find their way into the nucleus, where they regulate gene expression; and via non-classical pathways, as sex steroid receptors can be found outside the nucleus, including mitochondria, the endoplasmic reticulum, and the plasma membrane, where they activate different signaling cascades and exert their actions. Through these mechanisms, neurosteroids have significant effects on neurotransmitters such as GABA, serotonin, dopamine, and glutamate. Furthermore, studies show that sex hormones and their metabolites influence brain areas that regulate mood, behavior, and cognitive abilities.
We classify the effects of these hormones on the CNS as either activational or organizational. The activational effects modify neural activity in specific and non-permanent ways (i.e. modulating neurotransmitter synapses). Organizational effects permanently alter the structure of the nervous system through mechanisms such as: myelination, neural pruning, apoptosis (programmed cell death), and dendritic spine remodeling. A good example of these effects is the role that neurosteroids have in modulating the synaptic plasticity of long-term potentiation (LTP), via the above-mentioned mechanisms. This process refers to events that produce an increase in synaptic strength, which persists in time and plays an important role in memory and learning in the hippocampus, where estrogen has been shown to improve cognitive functions.
Through the mentioned mechanisms, neurosteroids regulate different brain areas involved in mood, behavior, and cognition. Therefore, the fluctuation of sex hormones during specific reproductive stages of a woman's life correlates with an increased susceptibility to develop mood disorders such as premenstrual dysphoric disorder, postpartum depression, and perimenopausal depression. Endogenous estrogen and progesterone levels also may affect different cognitive processes such as decision-making, emotion recognition, consolidation of emotional memory, and fear extinction. For example, women show improved verbal abilities and decreased visual-spatial abilities when estradiol and progesterone levels are high and the opposite occurs when estradiol and progesterone levels are low. These differences can be partially explained via the role that neurosteroids play in the physiological regulation of neurogenesis, neuronal survival, synaptic function, and myelin formation, thereby influencing neuronal plasticity. This makes them worthy of further studies that may make use of them to treat different disorders of the CNS, as recent studies have shown that neurosteroids could be effective in treating psychiatric disorders, such as schizophrenia, depression, and also against neurodegenerative disorders, such as Alzheimer's, Parkinson's, and multiple sclerosis.
In the same way that endogenous steroids influence CNS functionality, steroid hormones administered exogenously also exert their actions on the brain. Two of the most common ways in which hormones are administered to women exogenously are: 1) hormonal therapy during menopause and 2) hormonal contraceptives. When facing a need for the administration of exogenous hormones, consideration should be given to the stage of life each woman finds herself in since exogenous hormones will have different effects on the brain depending on the stage. For example, when treating adolescents, special consideration must be given to the temporal plasticity window of their developing brain, since it is a period when exogenous hormones may produce both activational and organizational changes in the brain that may have long-term effects. At the other extreme, women who are over 10 years past menopause must take precaution when initiating hormone replacement therapy (HRT), since they have been shown to have negative effects on the CNS, increasing the risk of pathologies such as Alzheimer’s disease or stroke.
However, it is important to consider that there are many situations when HRT and the administration of exogenous hormones is beneficial. For example, cases such as anorexia nervosa will require, as part of the treatment, the administration of hormones. Similarly, as women age, steroidal hormones decline and this could have negative consequences, such as hot flashes, osteoporosis, a decrease in libido, and depressive mood. Thus, special consideration for these individuals needs to be addressed. Also, the type estrogen and progesterone administered and the timeliness of their administration is of great importance. Regarding the type of estrogen and progesterone, certain progestins (lab-made progesterone), as medroxyprogesterone acetate, have some negative effects on myelination and their influence on mood and cognitive capacity have been shown to be deleterious, both in experimental and clinical trials (see full-version paper references). Considering the time of administration, it must be emphasized that the combination of estrogen and progesterone is not synergistic. Therefore, the simulteous combined administration leads to detrimental results when compared to either hormone administered alone or in sequence. Thus, when exogenous steroid therapy is indicated, healthcare providers should at least consider the stage of life, the state of the ovarian continuum that the patient finds herself in, the types of estrogen and progesterone administered, and finally, the timeliness and sequence of their administration must be precisely taken into account.
Finally, some questions to consider in future investigations include:
i. In terms of the ovarian continuum, what patterns of ovarian activity will have negative effects on the nervous system and what patterns will have positive effects?
ii. Should the effects of oral contraception (OCs) on the CNS be considered as adverse? Could they have positive effects?
iii. Is there a different effect on the brain when OCs are taken during adolescence? What is the effect of emergency contraception on the adolescent brain?
iv. To what degree should HT formulations be guided by physiological patterns of exposure (i.e., cyclical vs. continuous)?
In summary, the activity exerted by steroid hormones on the nervous system emphasizes the notion that achieving hormonal balance is a useful tool in seeking the well-being of women. Healthcare providers, as well as the general population, should be aware of this knowledge.

Our interview this time is with board secretary, Kristin Putnam. Kristin is in the final months of her term as a board member.  She lives in Shoreline, WA with her family.  Kristin will be part of a team of women who will represent WOOMB at the United Nations for the Commission on the Status of Women in March.
 
What brought you to learn and then teach The Billings Method™?
My NFP journey started with Creighton. I had charted it for four years before pursuing becoming an NFP teacher. The cost and the time needed for initial training made becoming a Creighton instructor impossible. But the woman who taught me Creighton encouraged me to look into the Billings Method. At the time, I was not thrilled with the idea of switching methods, but after that Teacher Training weekend, I was convinced that Billings was the method I would use, promote, and teach.
 
What were the most appealing differences in Billings vs. the Creighton Model method you previously used?
There are so many reasons! First, the solidity of the scientific research that has developed the method over the years is amazing. But with all of that depth of understanding, the Billings Method is so simple, straight forward, and is tailored to each woman as an individual. It doesn’t matter if you are regular, irregular, breast-feeding, peri-menopausal or have POCS, the method works for you, day by day, season by season.
 
Did The Billings Method™ play any role in your decision to convert to Catholicism?
It was in going to a BOMA Teacher Training that I first was exposed to the Church’s teaching on sexuality, so in this way, yes.
 
My husband and I had used NFP for our whole marriage despite being protestant. But, as protestants, we used it very protestantly: with no understanding of the Catholic Church’s teaching on marriage and sexuality. It was at my BOMA Teacher Training that I first heard the words “sins against chastity.” As a Methodist, I knew those words were English, but had no idea what they meant when strung together in that order. I came home from that weekend with a copy of Christopher West’s book, “The Good News About Sex and Marriage.” My husband read it, which prompted him to study Pope John Paul II’s Theology of the Body. We became convinced.
 
For us, the realization that the Catholic Church’s teaching on sexuality was true was the last straw. We had been inching toward the Church for about 9 years, and we saw the Church was good, but where we were in the Methodist church was fine too. At that point we realized that here was a truth that only the Catholic Church upheld. Then we started asking, “What else are we missing?” About one year later, my husband left his career in the Methodist church, and we both came into full communion with the Catholic Church.
 
What do you think fellow Billings teachers should emphasize about the Billings Ovulation Method® when promoting it?
Science and simplicity. The Billings Method is steeped in years of solid scientific research. This gives the method such strength in its accuracy and implementation. But you don’t have to be a scientist to use it! Women, all over the world, use this method effectively: rich, poor, literate, illiterate, urban, rural, etc.
 
You’ve done a great job as our board secretary.  What have you enjoyed most about being part of the board?
Thanks! I have enjoyed being able to contribute and take part in the many changes that have come to BOMA over the last 6 years, and I look forward to seeing how the organization will grow and flourish in the years to come.
 
Tell us about your family.
My husband and I have been married for nearly 13 years, and we live in the Pacific Northwest with our 7 children (so far). We are often asked as NFP teachers, if all of our children were planned. We like to say, “Yes. They were all planned at least 10 minutes in advance.” Which, in a nutshell, is the beauty of NFP, no? Our amazing kids are ages 10, 9, 7, 5, 4, 2 and 1. They all have their unique interests from robotics, to Spider-Man, to sparkly things, to interests in religious life. My husband is the Director of Faith Formation and Evangelization at our local parish and hosts Outside the Walls, a weekly program on Catholic radio. I am director extraordinaire of our home. We founded NFPAware in 2010 and it is still going strong as a vehicle for talking to the skeptic about NFP and contraception.