Natural methods of family planning: different types, effectiveness, advantages and disadvantages.

Natural methods of contraception are the methods in which no need to use any medical appliances.

These methods are practiced worldwide from many years. 

These methods are having popularity because of some specialties in them like:

-They do not need any medicine or medical appliance.

-There is no need to spend money.

-They can be practiced by the partners secretly and without religious restrictions.

There is no need to take help of doctors, no need of special training.

Most suitable to village couple and those belong to low socioeconomic status, who are hesitant users of contraception.

Worldwide around 10 to 15 million couples are practicing natural methods of contraception. 
In India around 3% of married women are practicing these methods.

Natural methods of contraception can be classified into two categories:

1. Fertility awareness – based methods means practicing periodic abstinence,

2. Withdrawal method that is coitus interrupts.

1. Fertility awareness – based methods:

Traditionally called as rhythm method or safe period.

These are methods of planning and preventing pregnancy by observation of the naturally occurring signs and symptoms of the fertile and infertile phases of the menstrual cycle, with the avoidance of intercourse during the fertile phase, if pregnancy is to be avoided.

These were practiced since ancient times but there was wrong timing. This was corrected by Knaus in Ausria and Ogino in Japan in 1929 by announcing that ovulation mostly occurs 12 to 16 days before the next period.

The principle of action in natural family planning methods is most fertile period of  a women is from the 10 th day to 18 th day, provided that is 28 days cycle. 
Coitus to be avoided during this fertile period of women, as determined by timing or calculating the time of ovulation.

In fertility awareness – based methods, the fertile period is calculated by :

a. Rhythm method

b. Basal body temperature method

c. Cervical mucus method

d. Symptothermal method

e. Standard days method

a. Rhythm method:

Also called as calendar method, it is based on ovulation takes place about 14 ± 2 days before the next period.

But during using this method it has to keep in mind that variations are common in menstrual cycle either due to age related changes or because of stress, medication and fever etc.

To practice this a calendar for 6 months to be maintained with a record of first day of menstrual cycle, so that the shortest and longest cycles can be noted.

By subtracting 18 days from the length of shortest previous cycle, the woman can get the first day of her fertile period in current cycle. 
And by subtracting 11 days the length of longest previous cycle, the woman can calculate the last day of her fertile period in current cycle.

To avoid pregnancy the couple should have abstinence during this period.

The failure rates are high with this method. It not suitable to women with grossly irregular cycles and it reduces the safe days of sexual intercourse.

b. Basal body temperature method:

Normally after ovulation the progesterone level in the body rises leading to increased basal metabolic rate, so there will be rise in the temperature by 0.5 to 0.8 ⁰F or 0.2 to 0.4⁰C in the luteal phase. 

By this we can know the timing of ovulation.

The woman has to record her temperature every day before getting up from the bed in the morning by keeping the thermometer under the tongue for 5 minutes. 
Special ovulation thermometer can be used.

The temperature should be recorded preferably in a basal body temperature chart.

The couple is advised to meet 3 days after the temperature rise in the postovulatory period.  
The end of preovulatory safe period cannot be detected in this method. The couple should either use some other contraceptive method or abstain from coitus in the preovulatory and ovulatory phases.

Improper recording of temperature, cold, fever, gradual rise of temperature during ovulation all these will affect the results from this method.

c. Cervical mucus method:

Cervical mucus method also called as ovulation method or Billings’ ovulation method.

This is based on the fact that changes occur in cervical mucus depending on the predominance of estrogen or progesterone at different times of menstrual cycle.

Following menstruation for one or two days no mucus observed called dry days.

Then sticky, cloudy mucus appears which indicates that ovulation is approaching.

At the time of ovulation the secretion becomes slippery, copious, clear can be stretched in between two fingers, and these are called wet days. They will persist for three days. Last day is called peak day. These days will indicate the peak of infertility.

Following this in the post ovulatory phase the mucus again becomes sticky and scanty and vagina becomes dry again till menstruation.

The couple can practice intercourse during menstruation, dry days in pre ovulatory phase and fourth day after the mucus discharge stops. They should abstain as soon as mucus appears in the preovulatory phase, during wet days in the ovulatory phase and for three days after the peak mucus day.

This is not suitable to women with abnormal vaginal discharge, till it is treated.

d. Symptothermal method:

It is based on basal body temperature method, cervical mucus method, events in the mid cycle like pain, light spotting, bleeding and breast tenderness.

All these are noted in the symptothermal chart. It is more reliable method.

The practice of sexual intercourse and abstinence are same as Billings’ ovulation method.

One modification of Billings’ ovulation method is there called modified mucus method by Dorairaj, that in a woman with regular cycles, on pre-mucus days when thick mucus is present intercourse is allowed and vaginal sex is permitted on the third day after the peak mucus day.

e. Standard days method:

The standard days method (SDM) is a natural family planning method for women with menstrual cycles ranging between 26 and 32 days.

It involves identifying the fertile days during each menstrual cycle.

Women can prevent pregnancy by avoiding unprotected sexual intercourse on days 8 through 19.

Most women using the SDM use a device called Cycle Beads—a string of color-coded beads that help women identify the days when they can become pregnant and the days when pregnancy is very unlikely.

Cycle Beads:

In this device there will be one black tube. This tube does not represent a day of the cycle. It has an arrow that shows which direction to move the ring.

Menstruation and after - day 1 to day 7: brown beads represent the days of a woman’s menstrual cycle when there is a very low risk of pregnancy.

Fertile Window - days 8 to 19:  white beads represent the days of a woman’s menstrual cycle when she is likely to get pregnant.

Low Fertility - days 20 to 32: brown beads represent the days of a woman’s menstrual cycle when there is a very low risk of getting pregnant

The dark brown bead:  it helps the women to know if they have cycles that are shorter than 26 days.  
If a woman has her period before she puts the ring on this bead, she has had a cycle that is shorter than 26 days. If this happens more than once in a year, this method is probably not appropriate for her.

End of Cycle - days 27 to 32: The day a woman starts her next period, no matter what bead the ring is on, she should move the ring to the red bead. Than the process starts over.

Last bead day 32: If a woman has not had her period by the day after she puts the ring on this bead, she is having a cycle longer than 32 days. If this happens more than once in a year, this method is probably not appropriate for her.  

Instructions to use:

The day menstrual period starts, the woman has to hold the cycle beads and move the rubber ring onto the first red bead.

Each day, she has to move the rubber ring onto the next bead, moving in the direction of the arrow.

She has to avoid sexual intercourse or unprotected sexual intercourse on days when the rubber ring is on any of the white beads.

She can consult the doctor if, she is not happy with the method,  she thinks that she is pregnant, she  wants  more information , she wants to start using another family planning method or she thinks that she may have been exposed to HIV infection or any other sexually transmitted infection.

The two – day method:

It is a new method.  It is appropriate to women with cycles of any length and regularity and apt for couples who can maintain abstinence for 10 to 15 days per cycle.

In this method the woman has to note her cervical secretions, if she can able to note any secretions on that day or yesterday she should consider herself fertile.  If there was no cervical secretions for two consecutive days, she is unlikely to get pregnant.

Effectiveness of Fertility awareness – based methods:

The failure rate of fertility awareness – based methods when commonly used 20 per 100 women years in the first year of use. It can be reduced to 1 to 9 per 100 women years with consistent and correct use.

With the calendar method, 9 pregnancies per 100 women years.

In basal body temperature method, 1 pregnancy per 100 women years, when intercourse takes place only in post ovulatory period.

In cervical mucus method, 3 pregnancies per 100 women years.

In symptothermal method, 2 pregnancies per 100 women years.

In standard days method, 5 pregnancies per 100 women years.

In two day method, 5 pregnancies per 100 women years.

Advantages of fertility awareness – based methods:

There are no side effects of drugs or devices and no physical side effects.

It will not affect the menstruation.

There is no need to buy anything so no financial burden.

It will improve the marital relationship as cooperation of both the partners is important.

There are no religious obstacles to use this methods.

Once the couple became aware of the method no need of follow-up or buying of products.

This can be used to avoid the pregnancy or to achieve it also.

These methods are suitable to uneducated and also for low socioeconomic people.

Disadvantages of fertility awareness – based methods:

To follow this methods most of the couple will need help from a health care provider initially for at least three cycles.

Cooperation is needed between the couple; they should have strong motivation and commitment to follow these methods.

Daily observation and charting is needed throughout the menstrual phase this may make some women feel these methods are difficult to follow.

Compared with other modern methods the effectiveness of these methods is less.

Unlike barrier methods these will not protect against sexually transmitted diseases or HIV.

The possible risk of having congenitally abnormal babies because of fertilization of aged ovum or sperm is not proved.

Medical eligibility criteria:

For cervical mucus method, symptothermal method and two day method which are symptoms- based methods:

Any non breast feeding mothers after 4 weeks of delivery can use these methods.

Caution to be taken when used by girls in post menarche period as cycles will be irregular in this condition.

Better to delay till the condition is corrected in case of:

Non -breast feeding mothers before 4 weeks.

Breast feeding   women before 6 weeks.

Women  with irregular vaginal bleeding.

Women  with abnormal vaginal discharge.

In women using drugs like anti depressants, lithium, anti- inflammatory drugs etc.

In women with diseases which will cause elevation of body temperature.

For rhythm method and basal body temperature method which are calendar-based methods:

Any women with vaginal discharge or with diseases which will cause elevation of body temperature can use this methods.

Caution to be taken when used by girls in post menarche period  or by women in perimenopausal period as cycles will be irregular in this condition.

Better to delay till the condition is corrected in case of:

Non -breast feeding mothers before 4 weeks.

Breast feeding   women before 6 weeks.

Women  with irregular vaginal bleeding.

Women  in post abortion period.

In women using drugs like anti depressants, lithium, anti- inflammatory drugs etc.

2. Withdrawal method:

The withdrawal method also called as coitus interrupts means discharge of semen outside the female genitalia at the end of intercourse.

This is one of the oldest method of contraception practiced worldwide.

In Asia around 4% of people are practicing this method as per the studies, in India around 2% of married women are practicing this method.

In this method at the time of ejaculation the male withdraws his organ and discharges the semen outside the vagina or female genital tract.

For better results the couple are instructed to use a second method of contraception particularly in most fertile days.

Effectiveness: 

Average failure rate with common usage is 18 per 100 women years in the 1^st year but with correct usage it is 1 to 9 per 100 women years.

This failure is mostly because of lack of self control or due to presence of small amount of sperms present in the discharge before actual ejaculation or due to ascent of sperms from the external genitalia.

Contraindication:

Premature ejaculation is the only contraindication for this method.

Advantages:

There is no need to spend money on medications.

No medical supervision is needed.

No prior preparation is needed.

And there are no any side effects related to procedure.

Disadvantages:

Some couple may complain of lack of full sexual satisfaction.

Failure rate is high compared with other methods.

The other drawbacks are this method needs great motivation and self control in the male partner.

The female partner may develop sex neurosis, pelvic congestion syndrome with dysmenorrhea or other menstrual problems but evidence regarding the relation with the method and these symptoms is lacking. Fear of pregnancy may lead to hypothalamic amenorrhea.

This withdrawal method when combined with barrier method or with vaginal tablets or with spermicides will give better results.