Anthropological and Methodical Differences of Natural Family Planning and Fertility Awareness–based Methods

Abstract

The term natural family planning (NFP), both in the scientific terminology and in the practical language of health policy, is often referred to as natural contraception or fertility awareness–based methods (FABM). “NFP. A guide to providing services,” issued by the World Health Organization (WHO) in 1988, presents NFP as a method inconsistent with any other contraceptive method but later published “Family Planning, a Global Handbook for Providers,” wherein NFP is not presented as a stand-alone method group but is grouped with FAB methods, which are combined with barrier contraception active during the fertile phase of a woman’s menstrual cycle if there is a desire to postpone pregnancy. In other words, the WHO family planning recommendations present FABM as one group of contraceptive methods. The WHO is the directing and coordinating authority on international health within the United Nations’ system. For these obvious reasons, the article mostly concentrates on WHO definition of FAMB. This article presents the anthropological and methodological differences between NFP (including and modern NFP methods that employ urinary hormone metabolite detection) and FABM and, through comparative analysis, determines that NFP is synonymous with neither FABM nor any of the methods of this group but is rather a distinct group of family planning methods.

Summary:

The term natural family planning (NFP), both in the scientific terminology and in the practical language of health policy, is often referred to as natural contraception or fertility awareness-based methods (FABM). The World Health Organization’s (WHO) is the directing and coordinating authority on international health within the United Nations’ system. WHO family planning recommendations present FABM as one group of contraceptive methods For these obvious reasons the article mostly concentrates on the WHO definition of FAMB. The article presents the anthropological and methodological differences between NFP and FABM and, through comparative analysis, determines that NFP is synonymous with neither FABM nor any of the methods of this group but is rather a distinct group of family planning methods.

Terminological Aspects of the Problem

Natural family planning (NFP) is a system of different methods in which the couple is aware of the fertile and infertile time of the woman’s menstrual cycle and act accordingly (Kipley and Kipley 2000). In general, methods belonging to NFP are classified according to older criteria (the calendar rhythm method) and modern criteria (such as the ovulation and symptothermal methods; Fehring 2004) and the observation of one or more fertility signs. The modern methods also are sometimes referred to as single- and multiple-indicator methods of NFP (Fehring 2004). Single indicator methods include the Billings method, the Creighton Model System, and the Two days method, all three of which observe mucus, and the Temperature method, which observes the basal body temperature (BBT). Symptothermal methods are multi-indicator, and—another NFP method is not based on observation but is exclusive for breast feeders—the lactating amenorrhea method (LAM) (Direito 2011, 72). NFP requires sexual abstinence during the fertile time if the couple wants to avoid pregnancy. NFP excludes using contraception and withdrawal during the fertile time (Kipley and Kipley 2000).

It can be noticed in scientific publications that NFP is often called one of the FABM with the main difference being only that couples refrain from genital contact during fertile days (Frank-Herrmann et al. 2007, 1310) in order to avoid pregnancy or engage in sexual intercourse during fertile time to achieve pregnancy (Manhart et al. 2013). In WHO’s (2018, 291) “Family Planning, a Global Handbook for Providers,” NFP is presented as a synonym for FABM: “Fertility awareness means that a woman knows to tell when the fertile time of her menstrual cycle starts and ends. Sometimes called periodic abstinence or natural family planning.” Thus, according to WHO’s definition, NFP may be combined with barrier contraception during the fertile phase if there is a desire to postpone pregnancy.¹ It is necessary to note that in this article description of FAMB is mostly based on WHO definition. This is based on the fact that WHO is the directing and coordinating authority on international health politics. WHO experts produce health guidelines and standards, WHO also supports and promotes health research and help countries (193 countries and 2 associate members are WHO’s membership) to address public health issues within the United Nations’ system (WHO 2007, 2). As stated in “Family Planning, a Global Handbook for Providers,” WHO (2018, vi) “encourages all national health systems and other organizations providing family planning to consider this new edition of the Global Handbook a key document to help ensure the quality and safety of family planning services.” In the Lithuanian health system, very likely in other countries as well, family planning policies are based on the WHO definitions. For example, at the official site of the Health Ministry of Lithuania is placed “The Methodic of the Contraception,” which is based on WHO family planning and contraception issues (https://sam.lrv.lt/uploads/sam/documents/files/Veiklos_sritys/Kontracepcijos_metodika_2016-11-22.pdf).

Definition of NFP and WHO’s Initial Agreement

NFP has progressed a long way until today. The term “natural family planning” was coined by Wilhelm Hillebrand, a German Catholic priest (Vollman [1977] from Fehring 2014). He was the first to develop a combination method using the temperature discoveries of Van de Velde and the Ogino-Knaus² calendar rhythm method in 1935 (European Institute for Family Life Education [EIFLE] 2017). In his letter to R. F. Vollman on November 30, 1949, he wrote “…I have used the basal body temperature, more and more successfully in the service of natural family planning” (Vollman 1979, 317). General use of the term NFP began around 1971 just prior to a Research Conference on NFP (sponsored by the Human Life Foundation and the Center for Population Research, the National Institute of Child Health and Human Development) in January 1972 (Spieler 1984). In the late 1970s, WHO began to take an interest in the promotion of fertility awareness and NFP. A prospective multicenter trial was carried out in different countries at WHO’s initiative and on which a number of scientific articles were published in the scientific journal Fertility and Sterility between 1981 and 1987.³ Having studied the results of efficiency trials, WHO concluded that in contrast to artificial contraception wherein efficiency depends in great part on the technical quality of the contraceptive, the efficiency of the natural methods was directly related to the quality of instruction given to the user and the motivation of the couple (EIFLE 2017). In 1988, WHO prepared and released a guide “Natural Family Planning, a Guide to Providing Services,” based on studies previously carried out. In the guide, NFP was defined as following: “natural family planning (NFP) is a term used to describe methods of planning or preventing pregnancy based on observation of naturally occurring signs and symptoms of the fertile and infertile phases of the menstrual cycle. Couples who use NFP to avoid or delay pregnancy abstain from intercourse on potentially fertile days” (WHO 1988, 1). It should be noted that WHO emphasized in that publication that NFP methods are methods of monitoring fertility but not methods of contraception.

NFP has two components: (1) fertility awareness, which requires observing and measuring the symptoms of fertility, which leads to a knowledge of the current probability of conception, and (2) modification of sexual behavior according to the aims of family planning, that is, if the couple has decided to postpone pregnancy or does not want to have more babies, then they do not enter into sexual intercourse during the fertile period; conversely, when attempting to achieve pregnancy, the observation of symptoms allows the couple to choose the most fertile time of the cycle (Skocovsky 2008). Thus, the basis and success of NFP methods lie in the ability to identify the fertile and infertile phases of the menstrual cycle and to exercise control over sexual desire. Both cognition and management require mind and will. In the case of contraception, knowledge of fertility and behavioral control are not necessary (Obeleniené and Narbekovas 2016, 21–26). So, in the 1988 WHO definition, besides the cognitive element—the determination of the fertile period in the woman’s menstrual cycle—there was also a value element—regulating sexual behavior in line with family plans (Klaus 2000, 89–95).

Mistakes in Equating NFP with FABM

Moving from the term Natural Family Planning to Fertility Awareness–Based Methods (FABM) started with discussions about the term NFP at the first WHO European Region workshop on NFP in August 1986, which drew attendees from fourteen countries. This was the first WHO European Region workshop on NFP, which is increasingly accepted as a positive and effective means of controlling fertility. A major recommendation of this workshop was that the term “natural family planning” should be replaced with the term “fertility awareness methods” in order not to imply that other contraceptive methods were unnatural and bad. The teaching of fertility awareness methods in a nonreligious context should address other forms of sexual activity and the possibility of using barrier methods on fertile days (WHO 1987). Soon thereafter, criticism against term natural family planning appeared in various scientific journals. Neumann (1989) argued from the viewpoint of behavioral biology and sexual behavior that the method of periodic abstinence is not obviously natural. International Planned Parenthood Federation (IPPF 1982) in the “Statement on periodic abstinence for family planning” also states that it is not considered that NFP methods are entirely natural, as they require abstinence from sexual intercourse for varying times during the menstrual cycle, sometimes for more than half the cycle days and are not “equal” alternatives to other family planning methods such as the pill, IUD, and condoms in terms of user-effectiveness. As Spieler (1984, 94) noted, “I find this embargo on the term NFP somewhat inaccurate for two reasons: first, although slowly disappearing, sexual abstinence within marriage is still traditional and widespread in many cultures, especially during the post-partum period; second, the ‘natural’ in NFP does not refer to sexual behavior but to the monitoring of natural physiological signs and symptoms of the fertile phase.”

Since 2001, NFP has not been used by the WHO European Office as an autonomous term, renamed as methods based on fertility awareness or periodic abstinence during fertile periods, and these renamed family planning methods have been grouped with contraceptive methods (WHO 2001, 6).⁴ In this way, after semantically removing the essential value element, NFP methods have been subdued within the broad terminology of contraception in terms of logic and values while in household use it has gradually become known as “natural contraception.”

In tandem with the terminological incorporation of NFP into contraception, the term “effective modern contraception” has become a counterbalance to NFP methods in scientific and health policy literature. This term includes, in particular, hormonal contraceptives (oral contraceptives, patches, implants, etc.) followed by nonhormonal barrier methods (Trussell 2004, 89–96). Alongside family planning, the alternative term “fertility regulation,” which is often used as a synonym for official and scientific use, has come into vogue. Fertility regulation is the process by which “individuals and couples regulate their fertility. Methods that can be used for this purpose include, among others, delaying child-bearing, using contraception, seeking treatment for infertility, interrupting unwanted pregnancies (emphasis added), and, in the case of mothers with an infant or a small child, breastfeeding” (WHO 2001).

The emergence of family planning and fertility regulation terms, usage patterns, and change in international official and working documents could be the subject of a separate study, but one of the prerequisites for NFP’s outbreak is the concern about mandatory abstinence from sexual intercourse during the fertile phase, as, according to NFP opponents, sexual abstinence is the main disadvantage of NFP and runs contrary to a human’s natural sexual needs. The opportunity “to have a satisfying and safe sex life” was justified at the International Conference on Population and Development (Cairo, September 5–13, 1994). The Cairo Conference for the first time formulated the concept of reproductive health⁵ and reproductive rights in the official UN use, which also reflects the differences between family planning and fertility regulation.

It should be noted that the disappearance of the term NFP from WHO’s use is in line with this organization’s approach to FABM. The last time WHO issued the “Natural Family Planning Guide” was in 1988, and unlike numerous other WHO publications on contraception, it is virtually unavailable. In its current policy and program publications, especially “Cornerstones of family planning guidance,” the effectiveness of NFP methods is not directly questioned. Nevertheless, for example, the issue “The medical eligibility criteria for contraceptive use” only devotes 3 pages for discussion of these methods without providing any bibliographic references, while 106 pages and 939 bibliographical references are given to other methods of contraception (WHO 2010)!

One can only guess as to WHO’s reserved approach to NFP, especially given the fact that it is healthy for women, cost-effective, and easy to learn (Ferris 2011, 173) regardless of a couple’s level of literacy. It is possible that this attitude is related to the fact that WHO currently has over eighty partnerships in the form of “official relations” and “working relationships” with nongovernmental organizations (NGOs) and the pharmaceutical industry (Burci and Vignes 2004, 89–107). For example, The International Federation of Planned Parenthood, which officially participates in the drafting and updating of the mentioned WHO recommendations, is one of the main implementers of condom social marketing (CSM) in the world (UNAIDS 2001, 18). The difference between social marketing and commercial marketing is that NGOs participating in CSM communicate directly with consumers through commercial marketing technologies, as the nonprofit status of an NGO allows to circumvent legal restrictions on the advertising of medical products established for producers or marketing authorization holders in various countries (Armand 2003).

NFP is mostly criticized because the limited effectiveness for postponing pregnancy. Contraceptive effectiveness is a “crucial concern to family planning program managers and potential contraceptive users” (Malarcher et al. 2016, 346). The effectiveness of NFP for postponing pregnancy remains a debatable issue. The latest systematic review of the effectiveness of FABM for avoiding pregnancy reveals that “the current evidence base for each method is small and of low to moderate quality.” Authors of the study identified several important limitations of the existing literature. No study achieved a high-quality rating across all thirteen criteria of the study (Peragallo et al. 2018, 10). In other hand, the hormonal contraception may well have no high-quality studies as well. According to Manhart and Fehring (2018), Dumitru, Gilbride, and Duane compared the quality of studies of oral contraceptives published since 2000 to quality of studies of FABM. This review underscores that Urrutia et al.’s finding, “there are no high-quality NFP studies is not necessarily worse than the status among the contraceptive literature” (Manhart and Fehring 2018, 341).

But effectiveness is only one criterion of family planning. There are many other aspects that couples prioritize when choosing family planning method such as side effects, level of medical intervention, and return to fertility (Malarcher et al. 2016, 349). Whereas contraceptive methods block, suppress, or destroy fertility, NFP helps couples to live with and recognize the gift of fertility. Contraception separates fertility from sexuality and at the same time gives rise to dynamics harmful to a “true conjugal relationship, including an increased risk for divorce” (Fehring 2018, 101). Strengthening mutual relations is the most important additional benefits of NFP.

The Anthropological Background of NFP that Shows How Different It Is from FABM

The Sexual Abstinence during the Fertile Phase Is a Strength of the NFP, Contrary to How It Is Discussed in FABM

When a couple practicing NFP wants to postpone pregnancy or has decided not to have babies anymore, the necessity of sexual abstinence is not the weakness of NFP; on the contrary, despite the fact that abstinence can be difficult at times, it is the method’s strength. It proves that NFP treats a person as more than just a biological social construct with uncontrollable sexual impulses. The mind and free will, required for cognition and self-restraint, are spiritual dimensions of the human person that distinguish him or her from all other living creatures. NFP treats the sexuality of the human being (as feminine and masculine, maternal and paternal) as an all-encompassing reality in which the sex drive is an integral part of sexuality and integrated into love. This is a major difference between NFP and contraception namely that the latter does not require two-person communication, fertility cognition, or control of the sex drive (in case of using FABM). The union of man and woman produces “the primary form of interpersonal communion. For by his innermost nature man is a social being, and unless he relates himself to others he can neither live nor develop his potential” (Pope Paul VI 1965, chap. 12). We cannot consider the mutual devotion of a man and woman in the form of exclusive conjugal acts as a purely biological phenomenon because human sexuality is the essence of the most important personality of a human being. Sexuality, by means of which “man and woman give themselves to one another through the acts which are proper and exclusive to spouses, is by no means something purely biological but concerns the innermost being of the human person as such. It is realized in a truly human way only if it is an integral part of the love by which a man and a woman commit themselves totally to one another until death. The total physical self-giving would be a lie if it were not the sign and fruit of a total personal self-giving, in which the whole person, including the temporal dimension, is present: if the person were to withhold something or reserve the possibility of deciding otherwise in the future, by this very fact he or she would not be giving totally” (John Paul II, 1981, para. 11).

NFP Is a Prerequisite for Experiencing True Conjugal Love as Unconditional Self-giveness and Human Fulfillment

Thus, in the conjugal act, the spouses gift themselves to each other. This comes from conjugal love, which is human and, hence, both physical and spiritual. This means that the conjugal act is not just about natural attraction and passion but about an act of free will, which seeks for love not only to “survive the joys and sorrows of daily life, but also to grow, so that husband and wife become in a way one heart and one soul, and together attain their human fulfilment” (Paul VI, 1968, para. 9). It follows then that if sexual intercourse does not express a comprehensive human experience but is merely a temporary quenching of sexual desire, then we are talking about the dehumanization of sexual intercourse. Dehumanizing occurs when a physiological sensation becomes a substitute for love when the purpose of such an act is sexual satisfaction rather than a union of individuals.

Conjugal love, therefore, is a love not wherein a person seeks advantages or loves the other for what can be obtained from him or her, but rather wherein a husband loves his wife for her own sake, and a wife loves her husband for his own. It is the kind of love that calls a person to love, that is, to love as a whole because love includes the human body, and the body participates in spiritual love. Thus,

conjugal love involves a totality, in which all the elements of the person enter—the appeal of the body and instinct, the power of feeling and affectivity, aspiration of the spirit and of will. It aims at a deeply personal unity, the unity that, beyond union in one flesh, leads to forming one heart and soul; it demands indissolubility and faithfulness in definitive mutual giving; and it is open to fertility. (John Paul II, 1981, para. 13)

Conjugal love is expressed by its characteristic conjugal acts, which have two dimensions of the marital union: the expression of love, that is, union of persons, and procreation. Expression of love comes from the spiritual character of the human being. Life-giving or procreation is possible because of human corporeality. Because love is expressed through the body and because a human being is an indivisible union of body and spirit (Catechism of the Catholic Church, 1993, para. 365), the dimensions of the conjugal act, according to Pope John Paul II “cannot be artificially separated without damaging the deepest truth of the conjugal act itself” (John Paul II, 1994, para. 12). What happens when the act giving life is eliminated from the conjugal act? One needs to look for the answer to this question in the notions of the nature of the person and the conjugal act. If the conjugal act is an expression of the unity of the individual as a whole, as an indivisible union of body and soul, the elimination of the procreative possibilities also affects both spouses and their mutual gifting to each other. In this case, they remove not only the biological element of the conjugal act. They change the conjugal itself by partially depersonalizing it (McCarthy, Bayer, and Leies 1989).

NFP Is Not Hostile to Fertility and Procreation

Through a conjugal act as a bodily dialogue between persons, spouses recognize their masculinity and femininity in a new way and how sexuality enables them to realize their calling for self-giving love. Spouses realize that they are not only husband and wife but also a potential father and mother. Thus, the conjugal act must be an expression of the love of the spouses and open to the new life that may crown this act (Grabowski 2004, 68–92). It must always be kept in mind that the conjugal act is not only about the relationship between a man and woman but is also tethered to procreation. The conjugal act, therefore, only has the full value of the unification of persons when it contains the conscious acceptance of the possibility of paternity. The spouses do not remain related only with each other during the conjugal act but at the same time relate to a new person who may be created by their unification (Wojtyla 1994).

This relationship with procreation, in turn, emphasizes the uniqueness of the spouse. After all, the spouse is the person with whom fertility is exclusively shared. To say with one’s body “I want you to be the father/mother of my children” shows unconditional and exclusive trust and confidence in that unique person. Also, it shows the love of the spouses for each other: “I love you so much that I want to be your spouse and that our conjugal love would be open to children, for whom we will both love and care.”

When the spouses eliminate fertility from the conjugal act, then there is no longer complete self-giving, and the spouse is no longer unconditionally accepted as a gift. In a sense, the spouse is “used.” The elimination of fertility is morally evil because it violates human dignity and violates the calling of a person to love in a self-giving love (Grabowski 2004, 68–92). A conjugal act can give life to a new person, so when the spouses are united by this act, their action must be accompanied by a conscious and willful attitude that “I may become a father” or “I may become a mother.” Without this attitude, the conjugal act is unjustified. Conjugal love itself requires the unification of persons, but unification of persons is one thing; their unification in the conjugal act is another. A conjugal act reaches the personal level only when accompanied by the notion “I may become a father/mother.” In the absence of this notion, it would be a personally inadequate union because it would rely only on the value of sexus and not on the value of the person. The unification in love is only replaced by reciprocal “consumption” (Wojtyla 1994).

By nature, the conjugal act is not always fertile. It is important to emphasize, however, that although many marriages are inherently infertile and lack the potential for procreation, they still have procreational meaning. Even by nature, an infertile act expresses conjugal love, which is characterized by personal and procreative dimensions. Such a conjugal act expresses the love of the spouses and the possibility of procreation (McCarthy, Bayer, and Leies 1989). On the infertile days, therefore, though knowing that the conjugal act will not be procreative, it retains the gifting of self. They deliberately do not exclude fertility, which is an integral part of self-giving (Grabowski 2004). Also, menopausal spouses express conjugal love even though new life cannot be created.

Only if spouses deliberately prevent procreation does their conjugal act lose the expression of conjugal love. Moreover, while such an act would be attempted to justify the expression of love, the elimination of fertility eliminates the heterosexual meaning of the human being created as a man and woman. In this sense, such an act is not an act of true sexual love and is no different from the same sex act (McCarthy, Bayer, and Leies 1989).

Entering into the conjugal act on infertile days of fertility and the deliberate removal of fertility from the conjugal act are fundamentally different. In the first case,

the married couple rightly use a faculty provided them by nature. In the latter, they obstruct the natural development of the generative process. It cannot be denied that in each case the married couple, for acceptable reasons, are both perfectly clear in their intention to avoid children and wish to make sure that none will result. But it is equally true that it is exclusively in the former case that husband and wife are ready to abstain from intercourse during the fertile period as often as for reasonable motives the birth of another child is not desirable. And when the infertile period recurs, they use their married intimacy to express their mutual love and safeguard their fidelity toward one another. In doing this they certainly give proof of true and authentic love. (Paul VI, 1968, para. 16)

Methodical Differences between NFP and FABM

According to WHO (2018, 291), “fertility awareness means that a woman knows how to tell when the fertile time of her menstrual cycle starts and ends.” As mentioned above, in WHO’s “Family Planning, a Global Handbook for Providers,” FAB methods are considered synonymous with NFP: “fertility awareness sometimes called periodic abstinence or natural family planning” (WHO 2018, 291). These guidelines cover two groups of FAB methods: calendar- and symptoms-based methods that include the Two Day, Ovulation, and Symptothermal methods. In all WHO family planning documents, it is recommended to combine FAB methods with barrier contraception: “FAB methods can be used in combination with abstinence or barrier methods during the fertile time” (WHO 2015, 266), or the couple avoids vaginal sex or uses condoms or a diaphragm during the fertile time. The couple can also use withdrawal or spermicides, but these are less effective (WHO 2018, 291–305). The delineation between NFP from FABM is that all modern NFP methods have a very strict limitation in that they cannot be combined with any contraception (EIFLE 2017). Also, modern NFP methods are based on daily observation of naturally occurring signs and symptoms of the fertile and infertile phases of a woman’s menstrual cycle, which is under the control of the hypothalamic–pituitary–gonadal axis (this is the main reason for daily cycle monitoring). The accuracy of women’s observations has been validated by solid scientific research (Direito 2011, 69, 72). The two main things that demonstrate that NFP is modern are systematic observation and recording of recurring events.

As has been mentioned, the woman’s cycle is under the control of the brain, and this explains why NFP methods not only treat each woman as unique but each cycle as well. Due to this, modern NFP methods generally do not include the calendar rhythm method, which is based on calculation but not on observation of fertility indicators. As has been explained, the requirement for NFP is that, if the spouses wish to postpone pregnancy or have no more children, it is necessary to not enter into sexual intercourse and genital contact during the fertile phase. Such a strict recommendation is proposed for two reasons: (1) the requirement of the method itself and (2) the anthropological and moral basis. The requirement of NFP methods to abstain from sexual intercourse and genital contact during the fertile phase—and to not use contraception—is due to the effectiveness of the method, which directly depends on the couple’s motivation and ability to recognize the fertile phase (EIFLE 2017, 160).

The anthropological and moral basis of NFP is the major assumption of the couple’s motivation, as it essentially allows the spouses to understand the full depth of conjugal love and its goodness, which makes the condition of refraining from sexual intercourse during the fertile phase not only a biological or methodological reason. For such spouses, NFP is no longer a method of a large group of family planning methods but a way of life that strengthens their marriage. The necessary condition of abstinence from sexual intercourse during the fertile phase does not weaken the love of the spouses but rather strengthens it because the spouses deliberately postpone the expression of love to each other through the conjugal act, that is, their choice to postpone pregnancy or to stop having more children is expressed by an act of the will.

The Ability to Integrate Sexual Abstinence into a Marital Relationship Strengthens Marriage

As Karel D. Skocovsky (2008, 65) states, for “successful integration of sexual abstinence into a relationship, two complementary processes are required: (1) sexual self-control and (2) saturation (fulfilling the needs) of intimacy. While sexual self-control includes the ability to regulate expressions of sexuality and its experience, the saturation of intimacy is related to an active building and maintenance of a relationship by nonsexual means.” In a recent survey of NFP users from the United States and seven European countries, a large majority of men (74 percent) and women (64 percent) felt that NFP helped to improve their relationship while less than 10 percent felt that the use of NFP had harmed their relationship (Unsel et al. 2017). NFP allows the spouses to better recognize each other’s needs. As stated in the study, most women (69 percent) and men (72 percent) felt that NFP helped them to speak about sexuality with their spouse and more than 80 percent of both men and women felt that NFP improved their knowledge and understanding of sexuality. NFP also helps to educate children, as spouses with children (85 percent of women surveyed and 82 percent of men) indicated the knowledge gained by using NFP assisted them in explaining sexuality to their children (Unsel et al. 2017, 3). As the National Survey of Family Growth shows, the divorce rate is lower among spouses who use NFP. This survey covered 5,530 women of reproductive age between 2006 and 2010 who indicated that they had ever been married. Among the women who had ever used NFP, only 9.6 percent were currently divorced compared to 14.4 percent of the women who had never used NFP who were currently divorced (x ² = 5.34, p < .21). Odds ratio analysis indicated that having ever had an abortion, sterilization, and/or methods of contraception increased the likelihood of divorce—up to two times. The frequency of church attendance decreased the risk of divorce. Although there is less divorce among NFP users, the reason might also be due to their religiosity (Fehring 2015, 273–82).

Conclusions

For more than two decades, NFP as an official term has been excised from the work of WHO and other international organizations, and NFP methods have been incorporated into the concept of contraception where they are contrasted with so-called effective and modern methods of contraception. The conflation of the old calendar rhythm method with modern NFP methods is intended to imply that NFP as a whole is outdated and does not meet the needs of modern humans.

Fertility awareness is an integral part of NFP, and looking at the historical development of NFP, fertility awareness was originally attributed to NFP. That is why logically NFP cannot be considered a subset of FAMB.

From the anthropological viewpoint, unlike FABM, NFP respects fertility, and spouses who use this method deliberately accept the possibility of maternity and paternity. NFP retains the integrity of the parts of the conjugal act that express love and life whereas FAB methods do not preserve this and the conjugal act is impersonal. Spouses practicing NFP deliberately manage the sex drive according to the needs of the spouse and family goals. Spouses who use NFP give themselves and receive the other unconditionally during the conjugal act, whereas FABM values the sexus but not the person. When applying FABM, self-control is unnecessary, so the dignity of the individual may not be taken into account as the other person may be “consumed” for sexual gratification.

The sexual abstinence during the fertile phase is the main anthropological and methodical difference of NFP and FAMB. Only human is rational and free. The mind and free will, required for the cognition of fertility and management of sexual desire, are spiritual dimensions of the human person that distinguish him or her from all other living creatures. When using NFP both spiritual dimensions: mind (cognition of fertility) and free will (management of sexual desire) are used. In the case of FABM as defined by WHO, only one spiritual dimension is used.

From the methodological viewpoint, unlike FABM, NFP is not contraceptive because NFP methods require abstinence from sexual intercourse and genital contact during the fertile phase if the aim is to postpone pregnancy. NFP methods are not combined with any other contraception, unlike FABM.

Against this background, it should be clear that NFP should be considered as a separate family planning group rather than part of the FAB method group; neither should it be used as a synonym of FABM nor understood as a form of natural contraception.

Biographical Notes

Birutė Obelenienė, PhD, is a professor of Theology Department and senior researcher of Research center on Marriage and Family in Vytautas Magnus university. She defended her doctoral dissertation at Vytautas Magnus University in 2007. She is the author of more than 40 scientific publication, compiler and coauthor of scientific monography “Medicine, ethics, and law about human until birth”, two books “Ethics of sexuality education” and “Fertility awareness and natural family planning”.

Andrius Narbekovas PhD, MD, professor and the head of the Theology Department and Research center on Marriage and Family of Faculty of Catholic Theology in Vytautas Magnus university. He defended his doctoral dissertation at Roman John Paul II Lateran University Institute of “Studies on the family and marriage” of Washington branch. He is the current chairman of the editorial board of scientific journal Soter of Faculty of Catholic Theology, is a member expert of Lithuanian Bioethics Committee at the Ministry of Health of the Republic of Lithuania. He is the author of more than 50 scientific publication, compiler and coauthor of scientific monography “Medicine, ethics, and law about human until birth”, co-author of books “Ethics of sexuality education” and “Fertility awareness and natural family planning”.

Jonas Juškevičius (1965-2019), PhD, was a professor of Institute of public law of Mykolas Romeris University. He has studied at Vilnius university of Lithuania, defended his doctoral dissertation at Lateran university in Rome. He was member of the board of Lithuanian Bioethics Committee at the Ministry of Health, the member of the working group on ethics in research and medicine of the Commission of the Bishops’ Conferences of the European Community (COMECE).