Learning Objectives
By the end of this section, you will be able to:
- Compare and contrast the different fertility awareness methods
- Explain coitus interruptus
- Describe abstinence as a method of contraception
The decision to use natural methods of contraception can be made by intimate couples with comprehensive, informed knowledge of available choices, risks, benefits, and long-term effects. Other factors that can influence the decision to use nonpharmacologic methods include religion, sociocultural expectations, cost-effectiveness, lack of insurance, and a desire to avoid the use of pharmacologic contraceptive products. Nurses can provide guidance and education to people desiring to use these methods.
Fertility Awareness Methods
Natural methods of contraception include fertility awareness methods (FAM), which are those that require the person who is menstruating to monitor the menstruation cycle and fertile window and avoid vaginal coitus (penile-vaginal intercourse) during the fertile window. Some people use a combination of fertility awareness and a barrier method during the fertile window. The six methods to monitor fertility discussed in this chapter are the calendar rhythm method, standard days method, Billings Ovulation Method, symptothermal method, basal body temperature method, and lactational amenorrhea method. FAM are 95 percent to 99 percent effective with perfect use (American College of Obstetricians and Gynecologists [ACOG], 2022c). Typical use efficacy is approximately 75 percent (Natural family planning, 2022).
Calendar Rhythm Method
The calendar rhythm method assumes that ovulation occurs within 14 days of the start of menstruation. To use this method, the menstruating person must know for certain the start day of the menstrual period and keep a record of the past 6 months of periods from start date to end date, to identify the shortest and longest menstrual cycle. The first day of the menstrual cycle is noted as the first day of menstruation. The fertile phase is calculated from 18 days before the end of the shortest recorded cycle through 11 days from the end of the longest recorded cycle. The individual/couple must abstain from vaginal coitus during that time frame. For example, if the individual has recorded a shortest menstrual cycle of 28 days and a longest of 35 days, the individual’s fertile time will be calculated as shown in Table 5.4.
| Calculation | Interpretation |
|---|---|
| 18 days before the end of the shortest menstrual cycle: 28−18 = 10 |
Fertile period begins at day 10 of cycle. |
| 11 days from the end of the longest menstrual cycle: 35−11 = 24 |
Fertile period ends at day 24 of cycle. |
| Fertile period is 14 days, from day 10 of the menstrual cycle through day 24. | |
Standard Days Method
The standard days method is a good option for those whose menstrual cycle is consistent, regular, and between 26 and 32 days in length. With perfect use, this method is 95 percent effective, and typical use is 88 percent effective (Weis & Festin, 2020). The nurse educates the patient/couple to avoid vaginal coitus or to use a barrier method between cycle days 8 through 19 (Hatcher, 2018). Downloadable apps can help patients to remember to abstain or to use barrier protection during these days, or patients can use CycleBeads.
Link to Learning
CycleBeads are a method of helping a patient follow the standard days method of birth control. They consist of a beaded strand that contains blue, white, yellow, and red beads. Blue beads mark days when pregnancy is very unlikely, white beads mark days when pregnancy is likely, the red bead marks the day when menstruation should begin, and the yellow bead marks when menstruation should begin for those with shorter periods (like 26-day cycles). This beaded strand can help a patient to either avoid pregnancy or become pregnant, if desired. There is also an app the patient can download for their mobile device if desired.
Billings Ovulation Method
The Billings Ovulation Method is the most “hands on” method among the fertility awareness methods and has been shown to be 96.6 percent to 98.9 percent effective with perfect use and 66.4 percent to 90 percent with typical use (Ayala-Ramirez et al., 2023; Turner, 2021). This method involves the person’s assessment of cervical mucus throughout the menstrual cycle. The amount and character of cervical mucus change throughout the menstrual cycle because of the levels of estrogen and progesterone in the blood and the position of the cervix. At the time of ovulation, the mucus becomes more estrogen dominant and presents as a much more copious, clear, and stretchable discharge called spinnbarkeit. The reason for this change at ovulation is to allow sperm to move with more fluidity through the vagina and uterus to get to an egg and fertilize it (Hatcher, 2018). Additionally, spinnbarkeit will appear in a “ferning” pattern when placed on a glass slide under a microscope. After ovulation, the consistency of cervical mucus returns to thick and sticky, due to an increase in progesterone, and creates a difficult passage for sperm (Hatcher, 2018). To use this method of contraception, the individual/couple must abstain from vaginal coitus during the first menstrual cycle to assess the cervical mucus for amount, feeling, color, and clearness of spinnbarkeit, and to become familiar with characteristics throughout the month (Hatcher, 2018). On the peak day of ovulation, the individual will notice increased wetness and clear, stretchable cervical mucus. This should be noted in the ovulation journal. To use this method of contraception and avoid pregnancy, intercourse should be avoided for the next 5 days. This method is appropriate for those who have irregular menstrual cycles.
Cultural Context
Contraception in Uganda
A study of Ugandan contraception use revealed that because of traditional gender norms, many times women were not involved in the decision-making process for family planning. A predominant theme in Uganda is the negative beliefs regarding family planning, including fear of infertility and beliefs that women who use contraception are promiscuous. When men are choosing contraceptive methods without consulting their partner, they choose more traditional forms of contraception instead of modern, long-term contraception.
Younger generations in Uganda are attempting to change these ideas. In a group aged 18 to 24 years, several spouses in the study stated they had more communication regarding contraception and child spacing. These women felt supported by their spouse. However, some women who had the support of their spouse could not use contraception due to lack of financial resources.
The study found that educated men had different ideas of family planning and limiting pregnancies. The writers recommend continued education regarding family planning for younger male and female Ugandans.
(Namasivayam et al., 2022)
Basal Body Temperature Method
The basal body temperature (BBT) method is a component of the symptothermal method. This requires the ovulating person to wake at the same time every day. Before even sitting up, the person obtains their BBT with a specific BBT thermometer. The person documents their temperature on a chart, online program, or smartphone app. Figure 5.2 shows a sample BBT chart. During ovulation, the BBT rises approximately 0.5°–1° F (0.3° to 0.6° C) and remains elevated until bleeding occurs, signaling the next cycle (ACOG, 2022c). By charting the BBT, the person can detect the subtle changes of a sudden drop immediately before the rise in temperature. The rise in temperature at ovulation is in response to increased progesterone levels that occur in the second half of the menstrual cycle (Hatcher, 2018). The most fertile days are 2 to 3 days before the temperature rise, meaning the person must track their BBT for several months to understand the pattern of fertile days during the cycle. To prevent pregnancy, couples should abstain from vaginal coitus or use a barrier method 5 days before ovulation until 3 days after ovulation to avoid fertile days.
Symptothermal Method
The symptothermal method is a combination of multiple fertility awareness methods and is >99 percent effective with perfect use and has 76 percent to 88 percent typical use efficacy (Nwadike, 2021b; Turner, 2021). To use the symptothermal method, the individual/couple will need information about menstrual cycle days, intercourse timing, how to assess cervical mucus changes, and basal body temperature (Hatcher, 2018). The nurse educating the individual/ couple regarding this fertility awareness method must be knowledgeable about various assessments and signs of ovulation. Some people recognize a sign of ovulation as a midcycle abdominal pain called mittelschmerz. Mittelschmerz is usually a one-sided, lower abdominal pain at the time of ovulation, sometimes described as dull and achy or sharp and sudden (Nwadike, 2021a). By educating the person about changes within their body, the nurse can help them determine what days they can abstain from having intercourse and avoid pregnancy (Hatcher, 2018).
Lactational Amenorrhea Method (LAM)
Lactational amenorrhea method (LAM) is a contraception method based on a person who is breast-feeding and meets all of the following criteria: exclusively breast-feeding at least every 4 to 6 hours, amenorrheic, and within the first 6 months after childbirth (CDC, 2023b). High prolactin levels in the person’s body prevent ovulation as long as the infant is exclusively breast-feeding without formula supplementation, the first menses have not returned, and the infant is nursing every 4 hours in the day and every 6 at night (CDC, 2023b). Ovulation occurs before the first menses postpartum and with lactation. If breast-feeding decreases for any reason, fertility may return quickly (Alberta Health Services, 2024). If any of these conditions is not met, a different method of contraception should be discussed, as the patient no longer meets the requirements of this method.
Populations for Whom Fertility Awareness Methods Are Not the Best Primary Contraception
Fertility awareness methods (FAM) are appropriate family-planning options for patients desiring to prevent conception. For example, many people of the Muslim, Jewish, and Catholic faiths choose not to use barrier and pharmacologic contraception for religious reasons. FAM are also ideal for monogamous relationships because of the lack of protection against STIs while requiring a supportive partner during designated periods of abstinence. For some people, hormonal contraception can be dangerous. For these populations, FAM may be a good contraceptive option.
Adolescents
Adolescents, generally, are not appropriate candidates for fertility awareness methods of contraception. Due to the need for deep understanding of menstrual cycles, trustworthiness of intercourse timing, and irregularities of menstrual cycles, FAM are not usually the first choice for contraception for this age group. Adolescents experience very high levels of menstrual cycle irregularities and may therefore have difficulty predicting when ovulation may occur. But sexual and menstrual knowledge that the nurse provides to adolescents leads to increased adolescent contraceptive use, decreased adolescent pregnancy outcomes, improved communication between adolescents and their parents, and improved communication in high-risk sexual situations (Lindberg et al., 2021; Santa Maria et al., 2017).
Perimenopausal Patients
Much like adolescents, perimenopausal people experience irregular menstrual cycles. The menstrual cycle can be 21 days in length one month; alternatively, the person can wait many months to experience menses again. This makes fertility awareness methods of contraception less effective. The individual/couple using this method of pregnancy prevention would have to abstain from intercourse for many days because of not knowing when ovulation was occurring (Hatcher, 2018).
Abstinence
The definition of abstinence is difficult due to the lack of consensus on what is and is not considered abstinence. For clarification, this text will distinguish between contraceptive abstinence and sexual abstinence. Contraceptive abstinence can be defined as preventing pregnancy by abstaining from vaginal intercourse, with avoidance of semen entering the vagina to fertilize an ovum. Perfect use of contraceptive abstinence is 100 percent effective. Sexual abstinence means different things to different people. Some believe it means all intimate acts between partners must be avoided, while others believe it allows any contact except penile-vaginal coitus. When providing contraception counseling, the nurse must determine the person’s definition of abstinence to ascertain if semen could come in contact with the vagina during their intimate practices. During counseling, nurses can educate and empower people that it is acceptable to tell their partners that they are not ready to have penetrative sex, especially if none of the contraceptive options fit their lifestyle. The nurse should counsel the person to have a backup method of contraception available (such as condoms or coitus interruptus).
Coitus Interruptus
Coitus interruptus, also called withdrawal or pulling out, is a method of contraception in which the penis is withdrawn from the vagina prior to ejaculation. This method requires large amounts of self-control. The partner with the penis must withdraw from the vagina completely before ejaculation occurs for this method to be effective. Studies have shown that sperm exists in the pre-ejaculate fluid, contributing to the high failure rate of this method of family planning (Killick et al. 2011). The benefit of the withdrawal method for patients is that it is free and easy to use, but the failure rate is around 20 percent (Planned Parenthood, n.d.-b). The nurse would educate the patient who chooses this method on signs of ejaculation and that even when the penis is withdrawn before ejaculation the method is only 80 percent effective.
Table 5.5 summarizes the pros, cons, and efficacy of the different fertility awareness methods of contraception. When discussing the effectiveness of contraception, the following terms are used: perfect use effectiveness, which is the rate of effectiveness in a clinical trial, and typical use effectiveness, which is how effective the method is when used in real life over a year.
| Method | Pros | Cons | Perfect Use Efficacy (% successful pregnancy prevention) | Typical Use Efficacy (% successful pregnancy prevention) |
|---|---|---|---|---|
| FAM | Free, fits religious requirements | Must have a thorough understanding of the method; not as effective with irregular menstrual cycles | 95–99 | 76 |
| Billings | Free, fits religious requirements, can be used with irregular cycles | Must be comfortable touching oneself, abstinence before and after ovulation; must abstain for at least 1 month to become familiar with their own cervical mucus | 96.6–98.9 | * |
| BBT | Free, easy to use | Must take temperature prior to any activity; multiple events can interfere with temperature regularity; only shows a change in temperature after ovulation, when fertile days have already occurred; must abstain before and after ovulation | * | 76 |
| Symptothermal | Free, easy to use, more effective because it combines methods | Same as FAM, Billings, and BBT methods | >99 | * |
| LAM | Free, no abstinence needed if all requirements met | Limited-time method; must meet all 3 requirements | 98.5–99.5 | 98 |
| Coitus interruptus | Free, no abstinence required | Must have great self-control | 96 | 80 |
| Contraceptive abstinence | Free; can have intimate contact without penis-in-vagina contact | Must have great self-control | 100 | * |