By Craig Turczynski
We had the opportunity to display and market our services at the FACTS (Fertility Appreciation Collaborative to Teach the Science) and AAPLOG (American Association of Pro-life Obstetricians & Gynecologists) meetings, which took place on April 5-7 in Indianapolis.
Without getting into the details of the logistics of travel, reminiscent of the movie Planes, Trains and Automobiles, we wanted to make you aware of this activity. Connecting with healthcare professionals was our primary goal. Being there not only reinforced our mission to people who are aware of BOMA, but there were numerous individuals who now know about us who had no idea previously. The conferences were inter-faith, and it is encouraging to see both Catholic and Protestant brethren involved in the pro-life mission. Faith aside, the most important factor is the solid science that continues to reinforce the healthier alternatives to conventional medicine’s promotion of birth control, assisted reproductive technology, and abortion. Legislative issues were also discussed along the lines of healthcare professional’s right to practice medicine according to their conscience. The federal update presentation given by Roger Severino from the HHS office was enlightening, and the HHS department’s recent efforts to protect religious freedom and the right of conscience in healthcare was encouraging. The full agenda of AAPLOG can be viewed here: https://conference.aaplog.org/.
There were many like-minded organizations who also exhibited at the conferences and opportunities for key strategic partnerships were explored.
Craig Turczynski, Ph.D.
Director of Development and Strategic Planning. BOMA
Attending the 19th Annual Catholic Men’s Conference in Worcester, MA
by Jennifer McManus
What a blessing to participate in the 19th Annual Catholic Men's Conference in Worcester, MA. During the vendor hall time between speakers, my husband and I spoke to men both younger and older, who looked at our printed materials and signed up for the BOMA newsletter so as to be more informed on NFP and BOM in particular. Some were happy to pass along the Preachable Message CD to their pastors and/or listen to it themselves. We also heard great things about the book The Estrogeneration. We were told it is a must-read book but to get ready to not put it down once you start.
We discussed the use of NFP for women with irregular cycles and that Creighton or sympto-thermal methods are not the only methods. We hope that the sharing of our message will encourage men at this conference, as well as bring hope for infertility with other couples in their lives. During the speaker sessions, vendors were asked to leave the hall, at which time, we were able to connect with other vendors. One woman is involved with the Catholic Medical Center in NH. There may be a possibility to be interviewed for a Catholic radio show called "This is the Day."
The nurses who work at a crisis pregnancy center were interested in the medical webinar series in May. There were also present representatives from three seminaries. One already had the Preachable Message book in their library and said how good it is. The other two were happy to have it and expressed great appreciation for the gift of both book and CD. I personally was asked to give a presentation to my diocesan deaconate program. We hugged some friends, were happily approached by strangers, and may never know how far our efforts or information may go.
By Eileen Wood
The Widow of Zarephath (1 Kings 17:8-16)
Then the word of the Lord came to [Elijah]. “Arise, go to Zarephath, which belongs to Sidon, and dwell there. Behold, I have commanded a widow there to feed you.”
So, he arose and went to Zarephath; and when he came to the gate of the city, behold, a widow was there gathering sticks; and he called to her and said, “Bring me a little water in a vessel, that I may drink.” And as she was going to bring it, he called to her and said, “Bring me a morsel of bread in your hand.”
And she said, “As the Lord your God lives, I have nothing baked, only a handful of meal in a jar, and a little oil in a pitcher; and now, I am gathering a couple of sticks, that I may go in and prepare it for myself and my son, that we may eat it, and die.”
And Elijah said to her, “Fear not; go and do as you have said; but first make me a little cake of it and bring it to me, and afterward make for yourself and your son. For thus says the Lord the God of Israel, ‘The jar of meal shall not be spent, and the pitcher of oil shall not fail, until the day that the Lord sends rain upon the earth.”
And she went and did as Elijah said; and she, and he, and her household ate for many days. The jar of meal was not spent, neither did the pitcher of oil fail, according to the word of the Lord which he spoke by Elijah.
The topic of money is something that tends to be quite difficult for most people to talk about in our society. In fact, people will often reveal their contraceptive mentality with perfect strangers in the checkout line at the grocery store (Saying things like “You have HOW many kids? I got my girl, I got my boy, I got no more” or “Two and through!”) and yet won’t share their annual salary with their closest friends or siblings.
As uncomfortable as finances might be to discuss, it is an important topic in many ways. God calls us to be generous in all areas of our lives, including our time, talent, and treasures. For those of us who are using and teaching the Billings Ovulation Method®, we have already struggled through the concept of being generous with our fertility and cooperating with God in bringing forth new life. But what about being generous in all areas of our life?
Tithing is generally thought of as giving a tenth of your income to charity. For those who strictly follow it, that tenth comes right off the top, even before Uncle Sam takes his share. Then, typically your local church will get half of your tithe while the other half goes to various charities of your choice.
My husband and I have handled our charitable giving in different ways over the years. At times, we just picked a random amount to give to church each week and went up a few dollars annually when we got a raise. At other times, we approached it more rigorously and looked at our yearly gross income, calculating 10% of that and compared it to how much we were giving. We found that, as generous as we thought we were being, it was well below 10%. We then worked slowly to correct that.
A missionary priest once put all of this in perspective for me by saying, “Does 10% of your money belong to God? No, 100% of your money belongs to God. He is just gracious enough to let you keep 90% of it. So, if you don’t give back that 10%, then you are stealing from God!” His words were tough and challenging, but they always stuck with me.
A funny thing about living life God’s way is that it actually becomes easier and even enjoyable. So, if you decide how much money to give away to charity off the top, you have already detached yourself from that money in your mind. It is as if it’s no longer yours. (Think of it like tax withholdings taken out of your paycheck so you don’t ever think of that money as being yours from the start. Only in this case, God doesn’t force you to give like the government does.) Now, you can have some real fun with it. Yes, fun! It becomes like a game.
Let’s think in round numbers. If your household earns $100,000/year, you are talking about $10,000 in charitable giving. Half of that should go to support your local church, meaning $5,000 or about $100/per week will go in the collection basket. But what about that other $100 per week? Well, that goes to an appropriate charity of your choice. Requests for donations are always coming in the mail, through email, and from family and friends. If you have children in Catholic schools, there will be many opportunities that way as well. And please don’t forget about BOMA!
Now, instead of feeling the stress of desperately “looking” for money from your budget to donate, you can just have fun giving away “someone else’s money” since it isn’t yours anymore!
In the biblical passage at the beginning of this article, God, through Elijah asks the widow to give away everything, even down to her last morsel of food. In obedience, she does what is asked and is rewarded many times over. Always remember, God will not be outdone in generosity. After all, He has all the money in the world!
For where your treasure is, there will your heart be also. Matthew 6:21
By Eileen Wood
Did you know there is a little-known gene found in all of us that directs the body to produce an enzyme called methylenetetrahydrofolate reductase (MTHFR)? If not, please read on. This topic can have huge implications for your clients and maybe even yourself since almost half of the population is affected to some degree.
Folate is vital for the body to make DNA, RNA, and to metabolize amino acids, which provide the body with energy, break down food, and contribute to growth and tissue repair. It is also essential for pregnant women in order to prevent neural tube defects. A critical point to note is that, contrary to common understanding, folate and folic acid are not the same thing. Folate occurs naturally in foods. Folic acid is synthetically made and added to vitamins and food.
In 1998, the federal government mandated the addition of folic acid to almost all of our processed food supply, especially grains and cereals. The idea was to ensure that pregnant women would get enough folate to prevent neural tube birth defects. This campaign seems to have been successful to some degree. But what about for the people with this MTHFR gene mutation, who cannot break down folic acid and convert it to folate? For them, the folic acid becomes a toxin. It eventually results in an abnormally elevated homocysteine level, which can lead to heart attack, stroke, Alzheimer’s, cancer fetal abnormalities, neural tube defects, placental abruption, and pre-eclampsia.
Recently, I was reviewing the history of one of my clients*. She had three babies, all born prematurely at 30 weeks, 30 weeks, and 33 weeks, respectively*. Her first delivery had the further complication of a placental abruption. I asked her, “Have you been tested for MTHFR?” to which she promptly replied, “Yes, I am compound heterozygous."
In this woman’s case, she was diagnosed one year prior to her second pregnancy and began taking folate at that time. She also went gluten-free and stopped eating other grains, especially those enriched with folic acid. It didn’t seem to be enough to prevent her second premature delivery at 30 weeks, but at least she was spared a second placental abruption. Also, her daughter was in the hospital for three weeks fewer than her older brother. Finally, after some additional time of being on a healthy, folic acid-free diet, her third pregnancy lasted an additional critical three weeks.
The MTHFR gene can have either no mutations at all or a couple of them. These mutations are dubbed “variants.” The two most common variants are MTHFR C677T and MTHFR A1298C. Being compound heterozygous means that my client has one of each variant. There are many different combinations that can occur. Typically, the more variants, the more potential health problems.
As Billings teachers, it is important to be on the lookout for the signs of MTHFR variants in your clients when taking their history, especially if they are struggling to conceive or have had repetitive miscarriages. Other red flags include folate deficiency, autoimmune diseases, chronic anxiety or depression, and elevated homocysteine levels.
Testing may also be done simply, at home, by ordering a saliva test such as those from DNA testing companies. One example is 23andMe (www.23andme.com).
Another resource is Dr. Jose Fernandez, an NFP-only physician with JMJ Family Practice which has offices in Kissimmee and Melbourne, Florida. Dr. Fernandez routinely tests for the genetic defect when working with patients who have infertility or frequent miscarriages. “I've been ordering MTHFR in my practice for the last four to five years. I was prompted to do this because of lectures I had heard detailing this genetic defect as possibly being involved in not only recurrent miscarriage, but infertility in general.”
How common is the defect? Dr. Fernandez says from his patient experience, he finds it in up to 40% of his patients. This number matches the estimates generally cited in the literature.
As Fernandez explains, “As we have long known, some birth defects are preventable by maintaining proper levels of folate and homocysteine. That is particularly important with women who have the MTHFR mutation. Replacement should occur by substituting folic acid supplements with those containing methyl folate or folinic acid instead. Dosages can begin with 400 to 800 mcg up to 3 to 5 mg. When considering MTHFR genetic variants it is important to also take into consideration other genetic variants. This can become quite complex and either a patient or practitioner should consider consultation with someone well versed in this arena.”
Remember, no natural foods have folic acid in them. When occurring in nature, Vitamin B9 is in the form of folate. However, when artificially supplemented, it is often in the form of folic acid. The bottom line is that this is just another reason to eat wholesome, non-processed foods. Some foods which are naturally high in folate are legumes, asparagus, leafy greens, beans, eggs, beets, citrus fruit, Brussels sprouts, broccoli, nuts and seeds, bananas, avocados, and beef liver.
To reach Dr. Fernandez, call his office at (407) 935-9012 or visit his website: www.jmjfamilypractice.com.
* Note: The client has given permission for her story to be anonymously printed in this newsletter and website.
Dr. Mary Martin consults with Dr. James Brown during a WOOMB conference in Melbourne, Australia.
Q. When did you first learn about the Billings Ovulation Method® and what was your next step?
I believe I was first exposed to the Billings Ovulation Method in July of 1999. My 18-year civil marriage had ended in 1998. I sought out the advice of faithful priest, Fr. Jack Riley, who reassured me that I could not go back to the nonsacramental marriage as it was. I was long overdue for confession (it had been 13 years) and he said, "by the way, you're not prescribing contraceptives or performing sterilizations, are you?" Fr. Riley made it my penance to research whether oral contraceptives were potentially abortifacients. I already knew that they were, but lacked the courage and grace to act on the conviction until I attended several conferences which were designed to convince doctors like me that it was possible not to prescribe. Of course, the first physician I met was not an obstetrician, so I argued with him publicly at such an event and remained skeptical until I attended a Billings teacher training in St. Cloud, MN taught by Australian senior teachers Marian Corkill and Gillian Barker. As Marian and Gillian presented, light bulbs went off continuously, and I took advantage of the materials and resources available, including traveling to Melbourne, Australia. Traveling there for the next world Billings conference allowed me to meet Drs. John and Evelyn Billings themselves and Professor Jim Brown.
Q. How did learning Billings impact your medical practice as a gynecologist?
Significantly, I had stopped prescribing contraception and performing sterilizations on March 1, 1999, but lacked a practical, simple method to recommend to patients as a substitute for contraception and sterilization. I was relying only on my residency training, which, while good, was comprised of "see and treat," without any attempt to determine the underlying problem which had created the symptoms. I've often said that learning the Billings Method made me a gynecologist. Soon, instead of being the radical feminist challenging poor Dr. Chris Kahlenborn at conferences (I subsequently apologized), I was the persistent questioner of reproductive endocrinologists in my own specialty, the guys who wrote the textbooks. It dawned on me, when I was told that my questions and methods were "archaic exercises in academic rigor," that perhaps grace was playing a larger role than any intelligence that I may have contributed.
Q. Over the years, you met some of the great pioneers such as Drs. John and Lyn Billings, Dr. James Brown, and Dr. Erik Odeblad. Tell us a bit about those experiences and a couple of the things you will never forget.
I brought home Professor Jim Brown's Ovarian Monitor from my first Melbourne experience and relied on his personal guidance to perform the testing in my practice over the course of two years. I was fortunate to spend time alone with him on each of several visits to Australia. The time simply flew by as we excitedly queried each other and, bless his heart, Professor Brown always made it seem as if he were also learning something from me. On the last visit, he sat front row at my lecture, and subsequently, at our prescribed private meeting, said that he wished he had 20 more years to live, as he was sure that Pilar Vigil and I were really "on to something" with the role of insulin resistance and its effect on ovulation. Sadly, he predicted at that meeting, we were not likely to meet again on this sphere, given his advancing age. I am so grateful that he was the mentor who influenced me most.
I had contacted Erik Odeblad by fax or telephone, as I recall, and subsequently flew to Chicago to accompany him to the University of Illinois, where I had studied medicine. He planned to meet fellow Nobel nominee and recipient, Paul Lauterbur, PhD chemist. While both Odeblad and Lauterbur were nominated for their use of Magnetic Resonance Imaging, Professor Lauterbur had applied MRI widely in the field of medicine, while Erik had used the technique to study the structure and function of cervical mucus. Never was there more contrast between the two! While Erik was polite and extremely modest, Lauterbur, and his physician wife, whom I remembered had given the most boring, inane nutrition lectures in my first year of medical school, were pompous, obnoxious atheists. I had just heard of Professor Odeblad's difficulties with the Swedish Board of Medicine while on our drive from Chicago to Champaign-Urbana. His religious views against abortion and later contraception prevented him from practicing in Sweden as an obstetrician-gynecologist. Fortunately, for all of us, Dr. Odeblad brought his wife and family to California to earn his PhD at Stanford University. We flew on to Dallas, where Erik gave a detailed lecture on intracellular transport of manganese and the properties of cervical mucus. Professor Odeblad entrusted me to edit a scientific paper in English and rewarded me with contributing authorship.
Q. You have also become a friend and colleague of Dr. Pilar Vigil of Santiago, Chile, who will be our final presenter in our upcoming Medical Professionals Seminar webinar series in May. Tell us about how her protocols for helping women with fertility problems are different than what physicians in the United States use.
Pilar and I met in Melbourne and, having both been mentored by Brown and Odeblad, had much in common. Pilar is also an obstetrician-gynecologist, but earned a PhD in human reproduction, continued her studies in the US at the Texas Institute of Reproductive Medicine with Emil Steinberger, MD, and continues research as well as clinical practice. As founder of the Reproductive Health Research Institute, Professor Vigil and colleagues have consistently published in peer-review journals and have compiled protocols for the diagnosis and treatment of the underlying endocrine problems which lead to gynecologic problems, infertility, and recurrent pregnancy loss.
Q. We hear that NaProTechology physicians use surgery to treat problems that you would not use surgery for. Please explain your approach and how it is different.
Professor Vigil is extensively published on the subject of Polycystic Ovarian Syndrome, which is caused by hyperandrogenism (excessive male hormones). NaProTechnology endorses surgical treatment of polycystic ovaries, which was abandoned by my specialty more than 30 years ago. Removing part of the ovary, as NaProTechnology recommends, in ovarian wedge resection, temporarily reduces androgen levels, but markedly reduces ovarian reserve and fails to correct the underlying endocrine reasons for hyperandrogenism. My specialty is still promulgating insulin resistance as the cause of PCOS. Whereas Professor Vigil has conclusively shown that insulin resistance is a feature of some, but not all PCOS, and that other endocrine causes, including hyperprolactinemia, hypercortisolemia, and acquired congenital adrenal hyperplasia are other causes.
Q. If a Billings teacher has a woman who needs a medical consultation, but is not able to travel to you, what is the process and fees for setting up a remote consultation with you? Is it helpful if they are charting using nfpcharting.com so you can see their chart?
Charts alone are rarely diagnostic, but the BIP and the lack of Peak are diagnostic clues. A combination of patient history, physical exam, laboratory values, and ultrasound are required for diagnosis. For those who are unable to travel to the office, telemedicine consults, nfpcharting.com, and labs can usually provide a diagnosis. As I have recently joined a primary care practice, and telemedicine is being rolled out on a new platform, telemedicine consults are on hold at the moment. I’ve had three infertility patients who I’ve worked with remotely conceive in the past 6 weeks. The protocols work.
Q. If you could meet with med students in their early phase of their education, what would you tell them?
Read and listen critically. Good training will instruct you on how to judge studies for bias. Remember that we are all products of our environments. Don't be afraid to ask the hard questions. Instead of just accepting the standard treatment of oral contraceptives to treat gynecologic problems, how about if we address the underlying cause and treat it?
Q. Finally, how do people contact you for consultations through your medical practice, Axis Healthcare?
The practice phone number is (918) 825-3777. I don't yet know the cost of the consultations. Axis Healthcare bills insurance.
Q. We appreciate that you’ve been an excellent resource. We are also grateful that you are one of our long time, faithful monthly donors. What can we do to spread the word more effectively to your fellow physicians?
The science of the BOM sells itself. Keep up the good work in exposing physicians to the science!
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.
From Left: Son-in-law Joseph, daughter Alexa, grandson Ronan, Rosa, Craig, son Daniel, daughter-in-law London, son Seth
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.
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.
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:
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
Final note from the BOMA newsletter editors: This article is not intended to be construed as medical advice. Please consult your physician with any personal concerns.
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.