How Natural Family Planning Fits into the Title X Program OFP Family Planning Research Grantee Meeting January 14-15, 2009 Washington, DC  Jule Hallerdin, MN, MPH, CNM Nurse Consultant Office Family Planning Office of Population Affairs

Family Planning and Public Health 1800-1900 Family size declined from 7.0 to 3.5 1900 Six to nine of every 1000 women died in childbirth One in five children died during the first 5 years of life Public Health facts from : Achievements in Public Health, 1900-1999: Family Planning CDC MMR December 03, 1999 / 48(47); 1073-1080

Family Planning and Public Health 1900 Distributing information and counseling patients about contraception and contraception devices was illegal under federal and state laws The timing of ovulation, the length of the fertile period and other reproductive facts were unknown

Personal Examples

Family Planning and Public Health 1912 The modern birth-control movement began Margaret Sanger initiated efforts to circulate information about and provide access to contraception 1916 Sanger challenged the laws that suppressed the distribution of family planning information by opening the first family planning clinic in Brooklyn, New York

Family Planning and Public Health The police closed her clinic, but the court challenges that followed established a legal precedent that allowed physicians to provide advice on contraception for health reasons 1930’s- a few state health departments and public hospitals had begun to provide family planning services

Family Planning and Public Health 1940-1957 Family size increased average number of children per family peaked at 3.7 1960- the era of of modern contraception began – birth control pill and Intrauterine device became available

Family Planning and Public Health 1965- Pill became the most popular method followed by the condom and contraceptive sterilization 1965 Supreme Court (Griswold vs Connecticut) struck down stat laws prohibiting contraceptive use by married couples

Milestones in Family Planning 1900 First standard certificate of death created 1915 First federal birth registration area created First family planning clinic closed after 10 days 1925 First manufacture (in US) of diaphragms 1928 Timing of ovulation established 1937 American Medical Association endorses family planning 1955 First National fertility survey conducted 1960 The birth control pill approved by FDA

Milestones in Family Planning 1960 IUD approved by FDA 1965 Supreme Court declares unconstitutional state laws prohibiting contraceptive use by married couples 1970 Family Planning Services and Population Research Act creates Title X of the Public Health Service Act 1972 Medicaid funding for family planning services authorized 1973 Supreme Court (Roe vs Wade) legalizes abortion First National Survey of Family Growth conducted7 1990 Norplant approved by FDA 1992 Depo-Provera approved by FDA 1993 Female condom approved by FDA 1997 Emergency use of oral contraceptives pill approved by FDA

History of Natural Family Planning in OFP Office of Family Planning: Guided by the Law, Regulations, and Guidelines: Congress enacted the Family Planning Services and Population Research Act of 1970 (Public Law 91-572), which added Title X, “Population Research and Voluntary Family Planning Programs” to the Public Health Service Act. Factors affecting choice to use natural family planning identified 04 April 2003 Contraception 2003; 67: 253–8 Researchers have identified a number of factors that may influence women's use of natural family planning (NFP) methods. "A discrepancy exists between the interest in modern methods of NFP and their actual use in developed countries," observe Rafael Mikolajczyk (Otto-von-Guericke-University, Magdeburg, Germany) and colleagues. To investigate possible causes underlying this discrepancy, the researchers administered a questionnaire to 456 women who had recently given birth, to determine their knowledge, interest, and use of NFP. Of these women, 223 were residing in Berlin, Germany, and 233 in Cracow, Poland. The results showed that women with knowledge of NFP and those who had used it in the past were more likely to express an interest in the method than other women, but these factors had no independent effect on their current decision to use or not use NFP. However, cultural factors such as religious belief affected whether interested women actually used NFP. In addition, both interest in and decision to use NFP were affected by women's perceptions of the reliability of the method, and acceptance of their own body. "These results suggest that increased access and cultural support would likely lead to a higher prevalence of NFP use in developed countries," the team concludes.

Natural Family Planning Section 1001 of the Act authorizes grants “to assist in the establishment and operation of voluntary family planning projects which shall offer a broad range of acceptable and effective family planning methods and services (including natural family planning methods, infertility services and services for adolescents)” The authorities considered NFP to be important to spell out in the ACT- Or did they think it needed to be spelled out because it would be ignored? Empahsis on NFP- Any way the bottom line is it is an important part of the “broad range of acceptable effective family planning methods”.

Natural Family Planning The mission of Title X is to provide individuals the information and means to exercise personal choice in determining the number and spacing of their children.

Natural Family Planning Natural Family Planning was one of the topics for which family planning research was solicited from 1985-1998: Topics included: Family Planning client behavior Adolescent family planning clients Male family planning clients Targeting of family planning services Clinic personnel behavior Organization and management of family planning services Role of private physicians Natural family planning Infertility services Counseling services

Natural Family Planning Title X Service Delivery Improvement projects on the topic of Natural Family Planning: 1989 Don Kramer Natural Family Planning Program Format Effectiveness 1989 John R. Weeks Factors Affecting the Choice of Natural Family Planning

Natural Family Planning Program Format Effectiveness 1989- Don Kramer Summary of findings: Team Teaching format 36% more cost efficient than the Creighton Model for instructing clients in the Ovulation method of NFP. Actual cost of service delivery for the Team Teaching format client was 64% of the cost of a Creighton model format client Both formats produced extremely similar results, in a broad array of relevant outcome variables, including continuation and pregnancy rates.

Factors Affecting the Choice of Natural Family Planning 1989-John Weeks Summary of findings: Private OB/GYN physicians were the least informed about NFP, and just over one-third knew about all three methods. NFP-only providers had the most knowledge, while clinic providers and administrators were in between. The single most identifiable barrier to the availability of NFP is skepticism among physicians about its use and effectiveness.

Examples of Title X Training Centers Focus on NFP Region VII Development Systems, Inc. Kansas City, MO NFP and Fertility Awareness: A conference call discussion for Title X clinicians about non-hormonal contraception - held 4/10/08 Unofficial telephone survey

Examples of Title X Training Centers Focus on NFP Region III -TRAINING 3, Family Planning Council, Inc. Philadelphia, PA Planning a 2 hour on-line interactive training for clinicians on Fertility Awareness – projected date 6/30/09

How Natural Family Planning Fits into the Title X Program NFP is a statutory requirement (FP Method) NFP is not widely used Need to find out why the method is not used more Provide accurate information to providers that will enhance provision of NFP counseling

Review of Program Goals for NFP Grantees Contribute to: Improved health outcomes Increased utilization of preventive health care- particularly among vulnerable and special needs populations Increasing the proportion of pregnancies that are intended

Natural Family Planning Questions?