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.
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.
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.
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
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
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.
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.
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.
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BOMA-USA provides education and training for The Billings Ovulation Method® which is a natural method of fertility management that teaches you to recognize the body's natural signs of fertility.