Natural Family Planning can be hard and expensive to use. Can new tech help?
It is no secret: Natural family planning has its discontents. A number of studies have shown that few Catholics use it, and it is not hard to see why. N.F.P. can be difficult, it can be frustrating, and occasionally it is impossible. I am a discontent myself, albeit a stubbornly faithful one, which is why I wrote a whole book about how ordinary, non-saintly couples can learn to navigate the spiritual, emotional and marital problems that N.F.P. sometimes brings into sharp focus.
N.F.P. is worth learning well and sticking with, despite all the trials it can bring. When we were first married, my husband and I did not know how to communicate well. We did not understand what sex was really about. We had no clue about how God’s will actually works in our lives. Sacrificial patience, generosity and transformative suffering were mysteries to us. They are not mysteries now but are daily practices, thanks in part to the rigors of N.F.P. I wrote my book to let other struggling couples know they are not alone, and that their suffering does not have to be in vain.
But one thing my book did not cover was the logistical obstacles to using fertility awareness based methods of family planning successfully. (Most now shy away from the more colloquial label N.F.P.) These obstacles are not negligible. It was not long ago that we desperately wanted to switch to another fertility awareness based method that would work better with my body, but we simply did not have the money; so we were stuck with an unsuitable method that caused frustration and confusion. Some struggling is inevitable and can bring about growth; but some is avoidable and causes only pain. A small cash grant would have made a world of difference for our family.
I wondered how common our experience was; so I designed some surveys and shared them on social media and on my personal website, targeting women who use or have used a wide range of different forms of fertility awareness methods. Nearly 700 women responded. Here is what I learned.
Some women love N.F.P. Some of them find it cheap and simple and empowering. Some of them find it pricey and labor intensive, but well worth the cost. Some of them say it healed their bodies, enriched their marriages and drew them closer to God.
But for others, N.F.P. brought one trial after another. The church teaches us to forgo birth control, and so they did, whether out of obedience, love of spouse or a desire to understand their own health better. But even if they were willing to take on the spiritual and psychological challenges of N.F.P., they found themselves stymied by logistical problems beyond their control—things that could easily be solved with something as mundane as money, or better marketing, or better organization or even something as simple as a babysitter.
Oddly enough, even as the church struggles to interest its flock in fertility awareness based methods for spiritual reasons, fertility awareness is having a moment in the secular world. Cosmopolitan gave N.F.P. some positive press, and so did The New York Times. The interest is fuelled partly by a slow but growing disenchantment with artificial contraception among women of a variety of backgrounds and faiths. There are now countless fertility awareness based methods (usually paired with targeted condom use in secular circles) on the market; and women, religious or not, are snapping them up. You can buy bluetooth-enabled super-thermometers for $300 and compact fertility monitors straight out of Star Trek that smile at you when you are fertile. It is a far cry from the days of a scrap of graph paper, a thermometer and crossed fingers.
It is a far cry from the days of a scrap of graph paper, a thermometer and crossed fingers.
There are dozens of slick fertility apps, many free, some with millions of downloads. Women who have no idea that the church pioneered fertility awareness are turning to fertility awareness methods because they cannot seem to get pregnant or because they are thoroughly sick of birth control side-effects like migraines, blood clots or mood swings and wandering I.U.D.s; and they are ready for something else, something natural.
Here is the frustrating part. The church has something natural and effective to offer, and it is not some antiquated calendar system. The U.S. Conference of Catholic Bishops has approved a number of fertility awareness based methods: Marquette, Creighton, Billings, Sympto-Thermal, Boston Cross Check and N.F.P.I. The church is, in theory, delighted when a couple want to manage their fertility naturally. And many of these methods offer some level of personal instruction, which greatly increases their effectiveness. But because they can also come with some psychological, cultural and logistical baggage, women who have powered through the judgment of the secular world find themselves facing obstacles from within the church itself.
What Women Want
Given the church’s desire for couples to practice fertility awareness based methods, you might think every parish and diocese would offer numerous, easily accessible and affordable ways to learn these methods in order to use them consistently and reliably. You would be wrong.
It is a long history, and it would be funny if it were not so maddening. Back in 1932, Leo Latz, M.D., of Loyola University Chicago wrote his slim volume The Rhythm of Fertility and Sterility, outlining the basic principles of calendar-based family planning, so couples could learn to chart their fertility cycles quickly, easily and cheaply. It sold 600,000 copies to a readership ravenous for information.
Dr. Latz, for his trouble, was booted out of the university, a decision some historians attribute to his attempt to put dangerous information in the hot hands of so many married Catholics who might make decisions without the blessing of a priest.
So much has changed since 1932. First came the pill; then came an onslaught of contraception, bringing with it the supposed promise of female sexual freedom, but also the all-too-common reality of hormonal mayhem, not to mention an intrinsic misogyny that treats the functioning female body as something in need of correction. The church has reformed its once forbidding attitude toward couples who wish to limit their family size. But there is much more work to be done.
One obvious problem is a simple shortage of instructors. While many couples have effectively taught themselves various methods of N.F.P., many more would be successful if they could find personal instruction, information and support from qualified professionals.
Of 290 N.F.P. users who responded to one of my surveys, 105 said distance from a qualified instructor made learning and using N.F.P. difficult, and nine said it made it impossible. Several women commented that they trained to become instructors themselves, simply because they could not find anyone else to teach them. Distance training by email and video chat is becoming more popular, but that cannot turn one instructor into 50. Mikayla Dalton, a Boston Cross Check instructor, said she has clients on six continents.
While many couples have effectively taught themselves various methods of N.F.P., many more would be successful if they could find personal instruction, information and support from qualified professionals.
“I’m waiting for that one intrepid biologist lady in Antarctica to reach out to me, so I can say ‘every continent,’” Ms. Dalton said.
Meanwhile, the monitor-based Facebook group she moderates has over 10,000 members, and Marquette claims 11,000 registered users; but Marquette and Boston Cross Check combined have 100 instructors. Women can learn some methods without an instructor, but charting emergencies happen: A couple packing their bags for an anniversary getaway may need help figuring out just how likely they are to conceive that weekend, and they need someone they can call.
Language and cultural barriers also create obstacles for many women and, combined, tend to leave low-income Catholics in the cold. Studies of fertility awareness based methods in the West have typically surveyed white, prosperous, educated, married, English-speaking couples. Universities often draw from local populations for studies, and this population reflects those demographics. It also reflects the fact that most instructors speak only English. Marquette, Creighton and Boston Cross-Check do have Spanish-language outreaches; but in general, fairly or not, N.F.P. in the United States is often perceived as a privileged spiritual lifestyle.
Considering the Cost
When couples want to use N.F.P., cost is often the biggest obstacle to success. Nearly a quarter of the women surveyed said cost was the primary reason they had chosen a method or changed methods, stayed with a method they are unhappy with, or quit or considered quitting N.F.P.
Many N.F.P. veterans scoff at the idea that charting one’s cycle is expensive. A thermometer costs maybe $7, and surely we all have pen and paper at home. And they are correct. There are cheap and free methods of N.F.P.
There is Billings, which teaches women to track cervical mucus. There are temperature-only methods. There is sympto-thermal (available through Couple to Couple League and in the popular secular book Taking Charge of Your Fertility), which tracks basal body temperature, mucus and other fertility signs, like cervical position. These are cheap, and information is easy to find.
Nearly a quarter of the women surveyed said cost was the primary reason they had chosen a method or changed methods, stayed with a method they are unhappy with, or quit or considered quitting N.F.P.
Cheap and accessible though these methods may be, however, their rules can be complex and overwhelming, especially during postpartum, weaning or coming off hormonal birth control.
And sometimes, like all methods of contraception, they do not work. A method is not cheap if it results in a method-failure pregnancy—one that occurs despite a couple following all the method’s rules—that wrecks your finances and pushes your marriage over the edge. Several women surveyed highlighted the grim irony that couples who can least afford the most highly effective forms of N.F.P. can also least afford an unplanned pregnancy.
In a recent meta-analysis of effectiveness studies of fertility awareness based methods (co-authored by Chelsea Polis of the Guttmacher Institute), Marquette scored far and away the highest—so high that the C.D.C. was forced to change its effectiveness scoring of such methods in general from a 24 percent failure rate to a 2 percent to 23 percent failure rate, acknowledging that not all fertility awareness based methods are born equal.
Marquette and Boston Cross Check are rated among the most effective methods, but they, along with Creighton, are also more expensive. A couple using these methods can expect to spend about $140 for the monitor, which is a one-time purchase; between $5 and $30 a month for test strips; and around $300 or more for instruction. The monitor and test strips detect estrogen rise and a surge of luteinizing hormone surge in urine, which helps predict ovulation. A couple can also supplement with progesterone test strips to confirm that ovulation has occurred.
The Creighton Model does not appear at first to be expensive, since it measures only cervical fluid and thus needs no special devices or test strips. But it is more regimented than Billings, partly to increase effectiveness, and partly because it is part of a larger world of women’s health care called NaPro Technology—and so its instructors go through 6 months of training, and practitioners, who are trained to manage more complex gynecological and reproductive issues, complete 13 months of training; Creighton clients are required to attend follow-up classes and to buy special paper charts and stickers. All that specialization adds to the value of the program, but it can also mean a client may spend up to hundreds of dollars a year to follow the model.
Marquette and Boston Cross Check are rated among the most effective methods, but they, along with Creighton, are also more expensive.
For some families this cost is not a concern. Some women I surveyed said they went into debt to pay for a method that worked for them and considered it worth it. Some said they had to train themselves to think of effective fertility awareness as basic health care, rather than as a luxury. Some women said that they just could not get affordable N.F.P. to work, but they could not face going back to the emotional rollercoaster caused by the hormones of artificial contraception. So they stopped having sex altogether.
Many couples have argued that health insurance plans should cover the cost of fertility awareness based methods, and some of them do, especially if it is taught in a doctor’s office by a health care professional, as Creighton and Marquette sometimes are. Some women use flexible spending accounts or health savings accounts to pay for monitors or other devices. But many insurance plans cover only a few methods of N.F.P or none at all, and Catholics understandably chafe at the idea that their chosen method of family planning is financially out of reach, while 18 kinds of artificial contraception are available to the insured at no out-of-pocket cost, and most states offer free artificial contraception to Medicaid recipients.
And while the U.S.C.C.B. makes it clear that dioceses are obligated to provide high-quality N.F.P. services to their flocks, it does not specify who should pay for it. In many cases, the diocese or parish pays, at least for the initial instruction. They subsidize cheap or free lessons, materials and follow-up sessions to anyone who wants to learn. But couples rarely have a choice of methods.
Most often, a couple is shunted into whatever N.F.P. method has risen to the top in that particular diocese or parish. Even in diocesan offices dedicated to marriage and family, N.F.P. instruction and access is rarely a priority. Perhaps a couple who serves as an instructor team for the Couple to Couple League happens to attend the 10:30 a.m. Mass, or maybe a new fertility care practitioner has moved into town and needs clients. The most accessible option becomes the default, both in terms of where couples are sent and what the church pays for.
Most often, a couple is shunted into whatever N.F.P. method has risen to the top in that particular diocese or parish.
But the method that is available and affordable is not always the right method for a particular couple. Of course, Catholics are free to use any form of fertility awareness based method, including secular-based methods not sponsored by the church. But often, the one they were sent to is the only one they know about; and if it results in too much abstinence, too much stress or a method failure, the couple may wrongly assume that N.F.P. in general does not work. In some cases, they know very well that another method would work better for them, but the money simply is not there.
Talking to Teachers
The researchers and teachers who develop and pass down information generally are not to blame for this financial pinch. They are well aware that it is hard to scrape together funding, as they have the same problem. While the secular world of technology surrounding medical care for women has an estimated $1 billion to work with, Catholic-based researchers often find themselves scrambling for cash.
Dr. Richard Fehring, who invented the Marquette method, suggests poking around eBay for used fertility monitors. The Marquette Institute for N.F.P. also collects old monitors and dispenses them to couples in need when it can. Marquette also offers a mucus-only method, which is cheaper but less effective, as it monitors fewer symptoms.
Dr. Fehring, an ardent researcher, is an N.F.P. pioneer who welcomes collaboration and change. He spoke to me enthusiastically of his colleagues in Bangladesh who are developing satellite phones that double as hormone testers. He is often on the road, comparing notes with secular researchers and trying to drum up some money from the National Institutes of Health. He believes he would win more grants if he were not Catholic.
Rachel Amiri, a fertility care practitioner (the name for a highly trained Creighton instructor), is also a tireless worker in the fields of N.F.P., weeding out bad information and encouraging the weary. As a mother of young children, she, too, is well aware that it is hard to find the time, money, energy and child care to show up for instruction and follow-up meetings. She calls the Archdiocese of St. Louis, Mo., where she is located, something of a “NaPro mecca,” where instructors are abundant and the archdiocese is generous in offering financial assistance to couples. The archdiocese’s N.F.P. office was established by one of the co-founders of the Creighton method; and as long as Ms. Amiri’s clients need that method, she is able to help them without saddling them with a big bill.
In other locations, it is possible that some parishes have money to help couples but do not understand the need or have not sufficiently advertised this fact, and cash-strapped couples do not know to ask. Of 671 women who responded to my survey, 366 said they did not know if their church covered all or part of the cost. More than one woman surveyed said she had offered money to her parish to subsidize another couple, but the money remained on the table, untaken.
Of 671 women who responded to my survey, 366 said they did not know if their church covered all or part of the cost.
Such person-to-person assistance, rather than institutional aid, is a very common stopgap. Boston Cross Check instructor fees have been set by the archdiocesan N.F.P. office; but some, like Ms. Dalton, allow clients to pay in installments, or they simply offer their services for free. Ms. Dalton and her husband also collect donations and disburse funds to couples who cannot afford monitors and test sticks. Marquette and Creighton instructors may set their own prices. One Marquette instructor has recorded an mp3 of herself teaching, which she offers free.
Complaints about the high cost of N.F.P. sting instructors, even as they ring true. One Creighton client said her friend teaches her over dinner, and the client repays her in margaritas. Another instructor said she has been paid in peach cobbler. Another said plaintively that she never entered the field to become rich, but is abashed to discover she is consistently losing money.
Not all instructors are willing to negotiate. One fertility care practitioner said simply that she deserves to be paid for her pricey education, expertise, time and materials. And she is correct. Even N.F.P. instructors have to eat.
But many N.F.P. consumers I surveyed also said their instructor’s attitude was a major stumbling block to their success, especially when teachers blur the lines between medicine, theology and lifestyle choices.
The ubiquitous guide The Art of Natural Family Planning, by John and Sheila Kippley, originally of the Couple to Couple League and now associated with N.F.P. International, drove away more than one otherwise willing couple surveyed, despite the low price tag of the method, because it blends information about follicles and fallopian tubes with censorious opinions on ecological breastfeeding and family beds. Some women who bottle fed their babies said the book made them feel like they were sinning. The materials have since been revamped, but many of those judgmental attitudes that condemn people for amoral parenting and lifestyle issues linger in Catholic circles.
Ironically, when N.F.P. classes are offered for cheap or free, the low-rent setting that often comes with low-cost programs can itself be off-putting.
Ironically, when N.F.P. classes are offered for cheap or free, the low-rent setting that often comes with low-cost programs can itself be off-putting. A willing bride will not win her skeptical new husband over to N.F.P. if she drags him to talk about sex with a stranger in a church basement festooned with kindergarten catechesis posters, Ms. Amiri said. Sound medical science loses its clout when its presentation is perceived as dated or amateurish.
Digital technology can help bridge that gap. Secular fertility awareness methods have apps aplenty. They do an excellent job of making fertility awareness seem mainstream, professional, medically sound and accessible.
Billings and Marquette and the Couple to Couple League have apps tailored to their methods. These enable women to share their fertility status quickly, easily and discreetly with their husbands and their instructors.
In September 2019, after years of promising its clients an app, Creighton began to offer a mobile-friendly website to replace its cumbersome paper folders and stickers. But the site involves additional fees as well as five follow-ups with an instructor who must approve the couple’s paper charting before they are given access to it.
Ms. Amiri says that an app was deemed too insecure and too apt to fall out of HIPAA compliance, which could leave clients walking around with sensitive medical information in their pockets. Sue Hilgers, one of the co-developers of the Creighton Model, said that their site is different from other fertility apps by design, because “the Creighton model can only be learned and used effectively with one on one teaching.”
Marquette, while otherwise lauded for its accessibility and sensibleness, has also received criticism in some online forums. The unofficial Facebook support group for Marquette and Boston Cross Check users was designed to give a basic outline of monitor-based methods and quickly swelled to 10,000 members. However, the Marquette Institute for N.F.P. issued a letter threatening legal action unless the group changed its name and severely restricted the kind of material it shares. The group subsequently changed its name and now includes only basic information, and users are told to ask instructors (or to find an instructor) for more information. The Marquette site does have an official online forum on their site for subscribers, with access to teachers, which is currently under construction for an upgrade. Dr. Fehring disputes that Marquette is unnecessarily proprietary, noting that the basic instructions are available to all and that it is possible to learn and use the method without hiring an instructor.
In fairness, what is sometimes interpreted as paternalism and gatekeeping may really be genuine concern for medical ethics.
In fairness, what is sometimes interpreted as paternalism and gatekeeping may really be genuine concern for medical ethics. N.F.P. professionals have the right to protect both their intellectual property and their reputations. If a woman who barely understands a method unintentionally gets pregnant, she may go around telling the world it was a method failure, when it was not. Even worse, if a poorly trained client brings a faulty Creighton chart to a NaPro doctor, the doctor will base decisions regarding treatment on bad information. N.F.P. professionals have a stake in making sure their clients know how to collect accurate information.
There is always a push and pull between accessibility and quality. Dr. Fehring calls the proliferation of secular fertility apps “the Wild West,” full of unscrupulous investors looking for a cash grab, with little scientific oversight. The Catholic researchers who developed the models on which modern F.A.B.M.s are based got their mandate directly from Pope Paul VI, who called upon medical professionals to teach not only good science, but good morals.
Serious harm can be caused when researchers market fertility apps without that steadying moral mandate. Wildly popular secular fertility awareness based systems like Natural Cycles and DAYSY were both recently caught out making overinflated promises. Natural Cycles, the first app approved by the F.D.A. to be marketed as contraception, was forced to reword its advertising after consumer complaints. And DAYSY claimed 99.9 percent effectiveness in achieving or avoiding pregnancy until someone took a second look at its studies and found this reliability was overstated. The scientific journal that published studies about these methods has retracted them.
But religious-based fertility awareness based methods can also be prone to overselling—although the urge may come less from a desire to profit and more from a desire to prove to a hostile secular world that they are legitimate. A defensive attitude can lead to exaggerated brand loyalty. Specialized instructors may not be as aware of the benefits of other methods or may be unwilling to acknowledge the flaws in their own, making them hesitant to refer frustrated clients to a more suitable method. Ms. Dalton herself was so incensed when a defensive instructor tried to blame her for a devastating method failure pregnancy that she went out and became an N.F.P. instructor herself, vowing that she, at least, would never treat a client that way.
While this one-to-one, personal encouragement and support can be hugely helpful, a more centralized database, institutional leadership and funding from the church are still needed.
Ms. Amiri also acknowledges that Catholics will send women to fertility awareness-friendly doctors with the promise that they will be treated with more respect and dignity than a mainstream fertility specialist can provide. Ever a realist, she admits that does not always happen.
“Just because they’re using bioidentical progesterone instead of the Pill doesn’t mean they’re going to listen to a woman’s concerns,” she said. But Ms. Amiri believes the new generations of instructors are more sensitive to women’s desire to be trusted and listened to.
Both women urge more transparency, more collaboration and more communication about natural family planning from the people who have lived it and know it best. Ms. Dalton especially enjoys the “nothing to report” threads that often crop up on N.F.P. support groups online. Wary new members can be jittery after seeing so many posts about questions and crises; so the silent majority who are doing well volunteer how many months or years they have been ticking along with “nothing to report”—i.e., no unexpected pregnancies.
There are countless unofficial support groups for every method; and a new, lay-led online membership community called Off the Charts offers advice, encouragement and practical resources, including access to instructors for charting help and priests for spiritual guidance. While this one-to-one, personal encouragement and support can be hugely helpful, a more centralized database, institutional leadership and funding from the church are still needed to help the many couples who seek assistance in learning about fertility awareness methods.
There is no accurate, up-to-date, comprehensive index of methods of fertility awareness based methods, of how much they cost, who teaches them and where to go to find out more.
The U.S.C.C.B. site links to overviews of many methods, and the websites of individual methods list the names of instructors, but these lists are often out of date. There is no accurate, up-to-date, comprehensive index of methods of fertility awareness based methods, of how much they cost, who teaches them and where to go to find out more.
Here is my wish list: The U.S.C.C.B. devotes money to N.F.P. research and app development. More Catholic universities incorporate fertility awareness education into their nursing programs. Dioceses incentivize parishes to subsidize classes and advertise financial aid. Individual methods hire tech-savvy people who understand social media. Priests and seminarians learn hard facts about various methods and about how N.F.P. plays out in real life. And someone gets paid a living wage to organize and maintain a comprehensive index of information about church-approved methods of N.F.P. It seems like a lot. But asking couples to use N.F.P. is asking a lot, and the church can and must do more to support them.
Years ago, when we were so cash poor we could not afford to switch methods, a friend gave me her used monitor. Our finances improved, and I passed along the monitor to someone else, who has since donated it to yet another couple. There is no substitute for person-to-person support in this most personal of endeavors. But there is also no reason the institutional church cannot do more to help.