When people think about family planning, they most likely think about it as a deeply personal choice—which isn’t wrong. But there’s another way of looking at family planning, and particularly at Natural Family Planning (NFP): through the lens of social justice.
Dr. Brian J. Burke is a staff physician in family medicine at a hospital on Guam. Together with his wife, Johanna, Dr. Burke has been teaching NFP for eight years. We thought his view on how NFP goes hand in hand with promoting greater justice in healthcare were fascinating and worth sharing.
First off, what is Natural Family Planning?
Dr. Burke: Natural Family Planning is another name for fertility awareness-based methods of family planning. These methods monitor a woman’s external signs of fertility in response to the changing levels in hormones that occurs throughout a woman’s cycle. There are four major signs that can be monitored, including: cervical mucus, basal body temperature, the cervix itself, and the absence or presence of luteinizing hormone in the urine. In monitoring the changes in these various signs, a woman can note the times in her cycle when she is fertile or infertile with a high degree of accuracy. A couple using a modern method of NFP (hint: not the rhythm method!) who is seeking to postpone pregnancy will know what times to abstain from intercourse in order to effectively avoid pregnancy.
Why do you promote NFP?
Dr. Burke: I promote NFP because it allows a woman to get to know her body, and to recognize that there are changes throughout the cycle in response to varying hormone levels; changes she can chart. The woman comes to know what’s normal and abnormal in her cycle, which enables me to address specific issues in the reproductive cycle, whether through targeted hormone therapy or support, correcting nutritional deficiencies, and/or treating any underlying medical conditions. Moreover, NFP has no side effects, and has an effectiveness of 99 percent for avoiding pregnancy when used correctly. It can also help couples with subfertility achieve pregnancy by allowing them to take advantage of “timed intercourse” during the woman’s fertile window.
The vast majority of women use some sort of hormonal contraception for family planning, all of which have a number of side-effects and risks. Most of the women using these methods don’t understand how their fertility cycles work, or understand that there is only a small window each month when they can get pregnant. Many are prescribed hormonal contraceptives to treat the symptoms of underlying medical issues and menstrual irregularities, with the idea that contraceptives “fix the problem.” In reality, hormonal contraceptives simply “cover up” the problem, because they function to suppress a woman’s cycle without actually addressing the cause of any underlying issues.
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The term “reproductive justice” in modern discourse often means access to birth control, abortion, sterilization, and even artificial reproductive technologies (ARTs). Do you agree with the association of “justice” with these therapies and procedures?
Dr. Burke: I think it’s a misnomer. When we take a step back, and look at the nature of reproduction on the biological level, we see that it requires an intimate act between a man and a woman to create a child naturally. This act is both unitive and procreative, bringing the couple together in both love and pleasure. If we look at this through the lens of true justice, we can’t separate out the biological from the emotional, in the sense that if a man and a woman are going to engage in this voluntary act, they need to be willing to accept the natural consequences of it. Now, that doesn’t mean every act has to result in a child, but it does mean that it would be unjust to use things like abortion or contraception to try to prevent the procreative aspect of this voluntary, intimate act. In short, the term “reproductive justice” has been misused in order to justify acts that are inherently unjust, in the sense that they destroy a human being, and/or disrupt the intimate act between a man and a woman. These technologies and procedures warp the sexual act from being one of true love and self-gift, into one that is a use of the body and the other. And how can we say we are acting justly towards another when we are, in fact, using him or her?
How might NFP do a better job of promoting true “reproductive justice” in health care?
Dr. Burke: NFP is the only family planning method that involves the couple together, so it requires communication and mutual decision-making about whether to engage in the marital act. In that way, the couple respects each other’s dignity in a deeper and fuller meaning of sex which avoids the use of the other’s body. NFP also allows the woman to avoid the damaging physical side effects of hormonal contraception. Furthermore, a couple engaging in sexual activity with the knowledge that it may result in a child are less likely to contemplate abortion, which promotes greater justice towards the unborn. Conversely, when a couple chooses to abstain during fertile periods, they are exercising greater responsibility over their reproductive decision-making, and in that way, showing greater justice to one another and to any future children they may have.
With NFP, the man has greater involvement and shoulders greater responsibility in reproductive decision-making than he would if the woman were using artificial contraception. Since sexual intimacy involves two people, NFP is far more just and respectful of a woman’s dignity than any situation that lays all the responsibilities and risks of family planning on her shoulders alone.
Do you see NFP as promoting greater justice in healthcare generally, even beyond the individual reproductive choices of specific women?
Dr. Burke: Absolutely. One of the greatest things about NFP is that it is empowering for women and couples together. With active engagement in the knowledge of her reproductive health, a woman isn’t just taking a pill to mask underlying issues. We know that hormonal contraception can impact a woman’s mental health, blood pressure, risk for heart disease and stroke, so even beyond reproduction, NFP has the potential to benefit other areas of a woman’s health. Moreover, the communication of the couple in NFP improves their relationship, which improves the overall health, safety, and well-being of the woman and family. When men engage in NFP, they better uphold the dignity of the women in their lives, which has positive impacts for society at large.
NFP also has the potential to address the underlying causes of subfertility and infertility in couples. Artificial reproductive technologies (ARTs) like IVF are costly and seek to bypass underlying issues contributing to infertility by “forcing” a pregnancy. But natural methods are equally (and sometimes more) effective at helping couples achieve pregnancy, as they seek to correct those underlying issues to allow a pregnancy to occur naturally. As a barrier to access, cost is a major factor in contributing to injustice in health care; NFP has the potential to lower the costs of reproductive health care, both in the achievement and avoidance of pregnancy.
What are some of the greatest challenges you face in promoting greater justice in healthcare through NFP?
Dr. Burke: Access to instruction. There have been many studies over the last 15–20 years confirming the efficacy of a growing number of NFP methods. However, they still cost some money to learn (albeit much less overall than the cost of artificial contraception or ARTs), and insurance companies generally will not cover those costs. It is an injustice that they refuse to recognize the efficacy, benefits, and desire for NFP, and I think a big part of that is because there’s no money to be made off of NFP by pharmaceutical companies. NFP, after all, is about knowledge; not devices or pills. As a result, “Big Pharma” doesn’t want to promote it, and in turn, insurance companies lack the motivation to cover it.
Another hurdle is that most of the medical field is unwilling to recognize the efficacy of NFP. This is due to a lack of education about it, especially in medical school. I think there’s also a “religious feel” to NFP that unfairly biases people against it, when in fact a growing number of people want to use NFP for non-religious reasons. Medical providers’ lack of training in a legitimate method of family planning and insurance companies’ refusal to cover instruction costs are both an injustice and a huge hindrance to couples who want to take advantage of NFP for whatever reason.
Overall, as people become more educated about NFP and how it works, and as they become more familiar with studies confirm its efficacy, they’re beginning to see it as a legitimate option for family planning. With more groups promoting education about NFP, particularly in medical school, I believe this bias will slowly continue to erode, and the better the potential will be for NFP to promote greater justice in healthcare.