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Couples' Views of the Effects of Natural Family Planning on Marital Dynamics

Richard J. Fehring
Authors: Leona VandeVusse, Lisa Hanson,
Richard J. Fehring, Amy Newman, Jaime Fox
 e-Publications@Marquette
Nursing Faculty Research and Publications Nursing
Originally published in Journal of Nursing Scholarship,
Volume 35, No. 2 (April 2004)
Reproduced with Permission
Marquette University

Little is known about how using various methods of birth control affect marital relationships and sexual dynamics. Few providers have made couples' dynamics a consistent area of follow-up. Early research indicated that natural family planning (NFP) was associated with psychological distress and that it affected marital relationships negatively (Crowley & Crowley, 1966; Marshall & Rowe, 1970).

Crowley and Crowley (1966) served as members of the Papal Birth Control Commission to study whether the Roman Catholic Church should change its position on family planning. The Crowleys surveyed 266 couples in the United States of America (USA) and asked whether the calendar rhythm method had helped or harmed their marriages. They received 158 responses, a 59% return rate. Responses were primarily negative; with 74% saying NFP had harmed their marriages. Couples reported difficulty with abstinence, loss of spontaneity, arguments, and increased fear of pregnancy. Similarly, Marshall and Rowe (1970) administered a detailed questionnaire to 502 couples who were currently using basal body temperature (BBT) and found that 48% of the respondents experienced some psychological stress from periodic abstinence, with unfavorable effects on their marital relationships.

Couples who participated in these earlier studies used older forms of NFP, including calendar rhythm and BBT. Since then, newer methods of NFP have been designed in which women recognize and document changes in cervical mucous secretions as the primary indication of fertility (Billings, Billings, & Caterinich, 1989; Hilgers, Daily, Hilgers, & Prebil, 1982). Modern methods require shorter periods of abstinence and are more effective. However, they still require partners to cooperate with up to 7-12 days of abstinence per month.

McCusker (1977) and Borkman and Shivanandan (1984) interviewed NFP-using couples and identified enhanced marital relationships, including improvements in communication, body, and fertility awareness, intimacy, shared responsibility, peace of mind, confidence, self-control, and spiritual wellbeing. Using a written questionnaire, Fehring and Lawrence (1994) interviewed 40 couples who used NFP and compared them with 40 couples who had switched to other methods. The authors identified positive and negative themes reported by both groups in the areas of intimacy, self-esteem, and spiritual well-being. Couples who continued using NFP rated significantly higher on spiritual well-being than did those who had switched to other methods.

Many recent researchers have measured satisfaction with NFP. In Boys' (1988) sample of 424 women, 72% reported method satisfaction. In a World Health Organization (1987) study in five countries (New Zealand, Ireland, Philippines, India, and EI Salvador), men and women participants reported 97% and 98% satisfaction respectively. Additionally, 83% of the women and 53% of the men reported no difficulty with abstinence. Although the majority of NFP-users in the survey reported method satisfaction, little recent work has been reported concerning effects on marital relationships. Also, few studies have included open-ended questions to allow participants to use their own words.

Promoters of NFP have stated that abstaining periodically from intercourse and using other expressions of sexual intimacy strengthened marriages {Billings et aI., 1989; Hilgers et al., J982}. Several positive effects of practicing NFP have been cited in the literature (Borkman & Shivanandan, 1984; Fehring & Lawrence, 1994; McCusker, 1977; Tortorici, 1979), including improvements in understanding human reproduction, communication, self-control, intimacy, appreciation of intercourse, and spiritual well-being. However, periodic abstinence and daily monitoring of menstrual cycles were stressful to couples' relationships, and lack of spontaneity, difficulty with abstinence, and fear of pregnancy were common complaints (Hefernan, 1977). Therefore, further study was needed. The purpose of this study was to identify the effects of modern NFP methods on marital dynamics by asking couples the same open-ended questions the Crowleys posed in the I960s.

Methods

The participants in this descriptive exploratory study were married couples who used or had previously used NFP methods based on cervical mucous signs of ovulation. A total of 1,400 couples were randomly selected from lists of people who learned NFP through two national organizations. The total number of couples who responded to the questionnaire was 334 or (24%). Of these, 248 (74%) were current NFP users.

A pair of identical questionnaires, revised from the Marshall and Rowe study (1970), was mailed to each couple. Instructions indicated that each marital partner should respond independently. The questionnaire contained 34 fixed-choice items about demographic information, marital relationships, and NFP such as spontaneity and coping with abstinence, and two open-ended questions used by the Crowleys in the 1960s: How did NFP help and how did NFP harm the marriage? Only data from the open-ended questions are presented in this paper. The university's office of research compliance approved the study proposal for human subject protection, including the purpose, consent, explanation of anonymity, and questionnaires.

At least two members of the research team read and coded each qualitative response to the open-ended questions. The coders discussed the data and the meanings of various phrases and word usages, and used content analysis (Krippendorff, 1980) to determine the coding categories. Inrerrater reliability between coders was consistently high (>90%). Any disagreements about meaning were discussed with a third coder on the research team until all agreed on the primary meaning, thus achieving 100% agreement about categorization of all comments. Categories of similar topics were then grouped together and identified as expressing positive or negative themes. The final major themes were robust enough to incorporate all the coded data and to summarize for descriptive analyses.

Findings

The average age of respondents was 40 years (SD=10.2). The average study couple had been married 15 years (SD=11.2), had used NFP for 10.5 years (SD =8.2), and had three children (SD=2 .0). Most couples were Roman Catholic (90%), Caucasian (85%), had at least 12 years of education (99%) and middle-class incomes (71% had combined incomes above $40,000).

Of the 334 couples (668 individuals) who returned questionnaires, 292 (87%) wives and 231 (69%) husbands responded to the open-ended questions. Many of them made multiple comments. The number of coded comments totaled 2,287, averaging 4.4 coded responses per respondent.

Respondents rarely made exclusively positive or negative statements. Of the 2,287 coded comments, 1,765 (74%) were positive and 671 (26%) were negative. The Table shows all seven themes (four positive and three negative), each with two to five subcategories, and their relative frequencies in the total coded qualitative comments, as well as their prevalence among wives and husbands. The relative contributions of the various themes to the total are shown in the Figure. (See published version for Figure)

Enhanced Relationships

The theme of enhanced relationships was most frequent and had the most subcategories and the most individual responses (see Table below and Figure in published version). This theme represented 717 (31%) of the total coded respondent phrases, indicating ways martial relationships had improved, such as greater communication and respect.

Deepened relationship. Couples described a stronger bond that the use of NFP created, including feeling less selfish and being more sensitive to their spouses' needs. They reported feeling greater love and more understanding for one another.

A typical response was:

Because it required mutual responsibility, respect, and communication, it has definitely helped us in our marriage relationship. Because periodic abstinence requires us to express our love for each other in ways other than intercourse, it had helped us to expand the "vocabulary" of love.

Improved communication. Discussing sexual intercourse, fertility, and child-rearing are integral I to using NFP successfully. Respondents indicated that communication between them and their spouses had greatly improved and that they were more open to a variety of topics. "It [NFP] has helped us to be closer and we communicate on a different level than just the ordinary ways. We seem to be very comfortable with each other."

Shared responsibility. Increased communication and harmony enabled couples to work together in planning to conceive or to avoid pregnancy. Respondents reported a sense of "shared fertility" with their spouses. Birth control became a shared responsibility as well, not solely the women's concern. "'Since we speak about our fertility on a daily basis (my husband charts and asks my observations daily) NFP has helped our level of communication remain very deep and intimate and always above-board, open, and honest."

Respected partner. As couples grew in their knowledge of each other and their shared fertility, comments indicated an increased amount of respect and pride in their partners. Spouses reported feeling more respected and less "used" sexually. One said,

It wasn't "my responsibility" (as wife) or the sacrifice I had to make… to "keep my husband happy." He is equally involved (he' charts). He understands and respect's my body more and I respect him more because he is supportive and not selfish.

Appreciated sexuality. Wives and husbands commented that abstinence enhanced their anticipation of sexual intercourse during infertile times, thus lessening the frustrations associated with abstinence while increasing their appreciation of their sexuality. They also reported that the sexual intercourse and other intimate activities including foreplay had improved. "Our sexual relationship is incredible. I have no complaints and truly believe the periodic abstinence [during] NFP causes us never to get in a rut sexually." Respondents also indicated that they were more open to discussing their sexual relationship with their spouses and had increased sexual activity.

Improved Knowledge

The second major positive theme was improved knowledge. In addition to enhancing marital relationships, 304 (13%) of the total comments made by respondents indicated their NFP knowledge helped them in a variety of ways.

Understand bodies, cycles, and selves. Husbands and wives described an increased awareness of the female cycle, the associated bodily changes, and related emotions. Several expressed a sense of wonder at learning the intricacies of the cycle. Others commented that their NFP knowledge helped them manage mood changes. As one said, "[NFP was] helpful to understand PMS symptoms for myself and my husband because of our awareness of my cycle. Thus, helped keep our moods, reactions, issues in balance, in perspective." Several people also commented that the knowledge fostered personal growth.

Learn other lovemaking. Discussions about sexual intercourse and NFP allowed respondents to learn more about their sexuality. These conversations resulted in what some described as redefining their ideas of a healthy sex life. "[NFP] gives you a much greater appreciation for your spouse and increases awareness of the sacredness and importance of sexual intercourse." As respondents described periods of abstinence, many emphasized enlightenment as they discovered other ways to experience intimacy, such as hugging and talking.

Enriched Spirituality

The third positive theme was derived from comments by 335 (15%) respondents who reported their spiritual beliefs or religious affiliation as reasons for using NFP. The three subcategories indicated they felt closer to God, congruent with church teachings, and more open to new life.

Closer to God. Individuals and couples reported that NFP enhanced their spirituality and enabled them to feel more connected to God. Some also said that being closer to God helped them feel more connected to their spouses. Respondents also indicated that NFP enabled them to recognize gifts from God, such as fertility, sexuality, and children.

Supported church teachings. Using NFP allowed a smaller number of respondents to live consistently with their religious beliefs and to avoid guilt.

NFP has definitely enabled me to understand the important role of fertility in a Catholic marriage. I believe the method literally enables me to be Catholic ... open to conception, to the partnership in creation a married couple has with God, while not being fearful that I will have more children than I desire or could handle. Without the method, I would have difficulty living up to my Catholic beliefs while enjoying my sexual relationship with my husband.

Open to new life. Roman Catholic Church teachings include the willingness to be "open to new life" or to welcome a child, whether or not the pregnancy was planned. "I think having her [second child] made us more open to planning two more. It has deepened our co-spirituality ... and has kept us open and sensitive to life, even though we think our family is complete."

Method Successes

The fourth positive theme was method successes. Respondents in 334 (15%) of comments reported using NFP because it met their family planning needs in ways that were natural and satisfying for them, whether they were attempting to conceive or to avoid pregnancy.

Spaced pregnancies. Couples reported that NFP gave them the information and "tools" necessary to plan their pregnancies and to space their children as they desired. "We were able to plan our last child and I saw a huge difference in my husband - he bonded right away with the pregnancy."

Several respondents indicated that NFP had been a successful method of family planning, although some eventually switched to other methods, such as sterilization.

Learned self-control. The ability to have children when they wanted to seemed to empower couples, enabling them to feel "in control" of their fertility and confident in the method. "About the time when you are ovulating is when you're most susceptible to having sex, because it is a natural time to be having sex, but on the other hand it teaches us self-discipline and ... priorities." Respondents also expressed pride in the self-control they had developed by using NFP.

Remained healthy. Many of the respondents commented favorably on the health-maintaining aspects of NFP, particularly the avoidance of chemical or barrier methods. "The pill ... eliminated my libido and my vaginal lubrication, and ... made me feel depressed and resentful toward my husband. The [NFP] method had no side effects. I felt free and powerful as soon as I stopped taking the pill." Several noted that the information they gleaned from NFP helped them to discover or resolve other health conditions.

Couples also reported negative effects of NFP on their relationships. Three negative themes were identified: strained sexual interactions, worsened relationships, and method problems. The two to three subcategories of each are presented, with one illustrative quotation.

Strained Sexual Interactions

Of the negative study comments, 307 (13%) dealt with negative effects of NFP on couples' sexual relationships. Most often cited were difficulties with abstinence, decreases in frequency and spontaneity, and unbalanced sexual drives between partners.

Difficulties with abstinence. An overwhelmingly negative aspect of NFP reported by both husbands and wives was the required abstinence, which added stress to their relationship in many ways. As one husband noted, "Abstinence is often difficult and can be prolonged. The 'honeymoon' phase often starts out great, but the full benefit is not obtained because she becomes less receptive and PMS kicks in." When avoiding pregnancy, couples often believed they needed to have sex even when they were tired, since a week or more might pass before they could resume sexual activity. This created performance pressure and impotence for some.

Other couples reported guilty feelings about engaging in various other sexual activities during times when abstinence was indicated. These activities included using alternate contraceptive methods and masturbation, whether solo or mutual. Some questioned issues like the "morality of orgasm outside of intercourse," creating additional strain with abstinence.

Decreased frequency and spontaneity. Another complaint was decreased spontaneity and frequency of intercourse because of the need to plan sexual activities. Both husbands and wives commented on this problem. "Our sex life has disintegrated quite a bit. All sense of spontaneity is gone. The passion is dead, or at least is most often suppressed."

Unbalanced drives between partners. A significant problem for women trying to avoid pregnancy was the inability to have intercourse during ovulation. During infertile phases when intercourse was "safe," their hormone levels and libido were lower. One said,

My sex is very low on infertile days when intercourse is okay. This causes trouble because my husband complains that I never want to have intercourse. I feel that my sex drive is about normal on fertile days, but then we can't have intercourse.

Worsened Relationships

In some cases, the negative effects of abstinence on the couples' sexual expression affected other aspects of their interactions, worsening their overall relationships. These respondents (6%) commented on anger, frustration, and misunderstandings resulting from partners' unmet sexual needs or women bearing sole responsibility for method use.

Anger and frustration. Abstinence was a frequently noted source of anger, frustration, tension, and fighting in some couples' relationships. Several noted that staying angry during abstinence allowed them both to avoid dealing with their sexual feelings.

My husband would not support periods of abstinence during periods of fertility. He insisted upon genital contact and orgasm and we often fight and have not slept together because of it or have poor or literally no communication ... I feel this is an excellent opportunity for growth and he feels it as a control factor on my part.

Misunderstandings resulted. NFP also created a variety of misunderstandings, creating tensions among partners. Several respondents felt hurt as a result. Some commented on feeling rejected during times of abstinence. Some expressed disappointment that they were not meeting their partners'' sexual needs. Another noted, "At times I have felt defensive or misunderstood because my husband believed I was glad or relieved to abstain."

Other tensions were created when the women were solely responsible for the couple's use of NFP or when husbands and wives did nor equally commit to using the method. Some wives viewed their husbands as unsupportive when they did not become involved in monitoring the cycle, leaving the complete responsibility to their wives for figuring out the mucous signs, recording them, determining the need for abstinence, and saying "no."

Method Problems

The third and final negative theme was method problems, expressed in 159 (7%) of respondents' comments. The problems were primarily related to complexities in interpretation of mucous signs resulting in fear of unplanned pregnancy, documented method failures with unintended pregnancies or irregular use patterns, or other difficulties such as lack of support.

Fear of pregnancy. Several couples, especially those wanting no more children, stated that they were in nearly constant fear of becoming pregnant. Several women said they had difficulty interpreting their fertility signs and did not understand where they were in their cycles. This led to unusually long periods of abstinence or unintended pregnancies.

I have, continuous, nearly always fertile type mucous, so NFP is extremely difficult for use. I am a bit bitter that it is not effective for us, but for religious reasons, don't dare using anything else. My husband and I are growing resigned to perpetual abstinence, bur that's not what we counted on when we got married. L am concerned he might not be content with a celibate life, but I am terrified by the thought of any sexual contact. Consequently our sexual romantic life is excessively strained… It's embarrassing to walk around with four children under the age of 4 and explain to every nosy stranger (contracepting Catholics as well) how "wonderful" NPF is.

A small number of respondents found learning NFP and charting to be difficult, time-consuming and tedious. Others commented on the difficulty of attending to their fertility signs daily throughout their childbearing years. These method problems contributed to the difficulty of using NFP and added to couples' fear of pregnancy.

Method failed. For some, the fear of an unintended pregnancy became a reality. Some saw pregnancy as a negative, ill-timed event that caused additional stress in their relationship, including financial. Others viewed it as a "gift from God" or a pleasant surprise. "We actually became pregnant ... using NFP. That was a very stressful time for us. We had a beautiful little girl, but this ... was the reason we decided to go back to the pill. Felt safer with this method."

After unintended pregnancies, some couples reported changing completely to other methods during the women's fertile times. Those choosing intermittent barrier methods viewed them as supplemental adaptations of NFP, not abandoning the NFP method.

Other problems. Several couples commented that they did not feel supported in their use of NFlP. For example, respondents wished that NFP was better respected by the medical community, the general public, and the clergy. Some felt ridiculed by those inside and outside the church, including family members, for following "outdated" church teachings. Others said they were afraid to admit their NFP use, even to health care providers, because it seemed that NFP was not considered a "real" form of birth control.

Rarely a participant expressed only strong negative reactions to NFP. A few described feeling forced to comply with NFP because of the spouses' religious beliefs. As one husband reported, "The man ... gets all the responsibilities of marriage and children but no protection .... There is nothing in this method for the man. It's all controlling for the woman."


Discussion

Compared to the results of the Crowley study done in the 1960s, the respondents in this study were dramatically more positive about use of NFP. The Crowleys reported that the periodic abstinence required for NFP was more harmful than helpful to marriages (74% to 64% respectively). The Crowley study participants were on average younger (mean 34 years) and had more children (mean 4.9). In the current study, nearly three-fourths of the comments made about NFP were positive, including many relationship benefits that enhanced marriages. The themes identified in the couples' qualitative responses were similar to those found in other studies with open-ended questions (Borkman & Shivanandan, 1984; Fehring & Lawrence, 1994; McCusker, 1977). The positive findings were consistent with those of studies that were primarily quantitative. For example, Oddens (1999) compared NFP to sterilization, oral hormones, intrauterine devices, and condoms and found that NFP-users rated higher on sexual pleasure than did those who used the other methods. However, less than 2% of those who use contraception in the USA use NFP (Piccinino & Mosher, 1998).

The current study has two major limitations. First, the response rare was only 24%. The intimacy of the subject and the requirement that both husband and wife complete questionnaires may have been burdensome and decreased the response rate. Further, the use of open-ended questions following a 34-item fixed-choice questionnaire may have limited the range of qualitative responses by suggesting topics. Quantifying the qualitative responses may have overrepresented common phrasings while underrepresenting outliers. Most respondents viewed NFP as having both positive and negative marital effects. A person may have responded by saying that abstinence had been very difficult early in their marriage, but they had later learned to cope with it. By coding into dichotomous categories, specific meanings and changes in couples' experiences with NFP that occurred over time may have been missed.

The second study limitation was the sample composition of a self-selected, homogenous group of mature, mostly Roman Catholic NFP users. Although a wide variety of contraceptive options were readily available, NFP remains the only method endorsed by the Roman Catholic Church for limiting family size (Lawler, Boyle, & May, 1998). Many of the respondents may have believed that NFP was their only contraceptive option. Further, couples using NFP because of their religious beliefs may feel compelled to report more satisfaction, thus giving biased responses. A more diverse sample may produce different findings. On the other hand, the mostly positive responses may be related to the shorter periods of abstinence required by modern NFP methods. Further studies may clarify these issues.

These findings have several implications for practice. First, NFP education is primarily offered through religious-based organizations in the USA, thus limiting access for the general population. A broader population might benefit from access to NFP. Education about NFP by public clinics that offer multiple methods has been attempted in Italy (Girotto et aI., J997) and the Philippines (Infantado, 1997) with mixed results. Further, NFP counseling is time consuming and therefore it may be difficult for clinicians to offer, therefore necessitating referral to a certified NFP instructor.

A second implication is that couples reported that NFP was not in balance with women's natural sexual rhythms. For some women, their peak desire was during their fertile periods, followed by diminished or absent desire during periods of infertility, leading to less frequent intercourse or unintended pregnancies. Although NFP teachers encourage the use of nonsexual means of expressing intimacy during fertile times, the cyclic nature of sexual desire needs to be better understood by practitioners and researchers.

Conclusions

Couples in this study reported both positive and negative aspects of NFP. Providers of family planning services need to become fully informed about NFP to adequately present all the options to their clients. The benefits of couples' knowledge, communication, and enhanced relationships, without exogenous hormones and technologic devices, might lead to wider use. As one respondent noted, "Natural family planning is the best-kept secret right now. The only negative is that it needs more publicity and for society to see its credibility."

References

Appendix

Table. Frequency of Qualitative Responses by Category


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