RE: simple versus complex NFP

[Guest guest]

Dear Dr. Fehring (),

I think there is a place for simple methods that can " be

taught in 10 minutes. " I don't mean " better than

nothing " as a negative statement, but as a relatively positive

one, depending on the setting. But there are some issues to

consider-

NFP requires behavioral change, especially if it is to be NFP

rather than BAFT (barriers at fertile time), etc. Behavioral

change will usually be easier to effect in the context of an ongoing

relationship with an NFP teacher than in one or two 10 minute office

visits (in my observation is this is usually the case).

Couples with more complex issues (such as infertility or

gynecologic problems) who want to use NFP data to help manage their

condition do better with more detailed instruction in more detailed

methods, in my clinical experience.

I have had the experience on quite a few occasions of both

patients and colleagues getting " 10 minute " instruction in

one method or another, assuming it would be adequate, and then being

surprised and totally negative thereafter when the method " didn't

work " . A lot of complex issues here, but not a good outcome

when they decide all NFP doesn't work based on these

experiences.

If a simple method is relatively good but not optimumly

effective, that trade-off needs to be made extremely clear to the

user. Do they prefer simplicity at the expense of some margin of

effectiveness?

I don't think it is optimum medicine for diabetics for me to try

to do complete diabetic teaching in a 10 minute office visit.

Likewise I don't think it is optimum reproductive medicine for me to

try to teach NFP in a 10 minute office visit. That's my

perspective.

But these are issues that can be studied with data, not just

opinions. I look forward to future studies that can address how

much teaching is really needed for optimum use by specific couples in

specific situations.

Joe

Stanford quote: "Yes there are

methods of NFP that can be taught 5 or 10 minutes (and they may be

better than nothing), but I believe that the best NFP instruction will

not generally fit into office visits, but should be done as a separate

service. It helps to have the NFP instructor available in the

same office or very accessible close by."

Dear Dr. Stanford (i.e., Joe):

Thank you for your perspectives on short NFP methods,

but for the sake of conversation (on this NFP discussion list) -

what standards or criteria would you use to define "the best NFP

instruction" -- and why do NFP methods that would only require a

short 5 - 10 minutes be only "better than

nothing"?

For the most part we are competing with birth control

methods that can be provided in a short office visits - e.g.,

hormonal pills; condoms; depo shots - methods that do not require a

lot of behavioral change.

When Sandrock, CNM mentioned that the TwoDay

method was a "no brainer", I thought that is a good criterion for

a method of birth control i.e., "simple to use" and I would add

"simple to teach" and according to the latest study - it is

effective in helping couples avoid pregnancy. If the method is

effective in helping couples to achieve their goal of avoiding

pregnancy, it is simple to use, and it does not separate the unitive

from the procreation act, is that not a good method? You can

reach many people with simple non-complex methods. Not always

easy to do with complex methods - that require extensive training of

teachers and of the couple users. And I am not saying that easy

is always the best.

I would also add that changing behaviors will occur

faster when we can reduce behavior hurdles - like learning complex

methods of NFP and requiring extensive group teaching and/or

follow-up. I believe that Larry Severy, PhD (psychology

professor at the University of Florida) mentioned at the Marquette

conference in 2002 - couples would prefer to use nothing --- but if

they have to use something - it needs to be simple and accurate.

Furthermore, if health professionals could incorporate teaching a NFP

method into their busy office practice - then maybe more health

professionals would and could provide it.

Your thoughts?

Hope all is well.

J. Fehring

Professor

Marquette University

PS - please do not take this as an attack on any

one method of NFP --- it is a general comment on modern methods of NFP

(OM, STM, etc) - including the Marquette Model. We have a hard

time getting couples to come to one group session and a follow-up.

--

______________________________

ph B. Stanford, MD, MSPH

Health Research Center

Dept. Family & Prev. Med.

University of Utah

jstanford@...

[Guest guest]

Dear Prof. Fehring (),

I know we discussed it already some time ago - but still some comments:

1) Effectiveness of any family planning method is a theoretical

construct. The sentence "this method has such effectiveness" is

formally wrong - effectiveness is conditional on many attributes of the

given study, of the population under study etc.

2) Effectiveness is an average measure: couples contributing cycles in

effectiveness study differ considerably on individual level in

parameters which are unknown (for example baseline fecundity) and known

(for example age, parity); additionaly couples differ on the

behavioural level.

3) There is some but rather limited evidence, that simple methods can

achieve a similar use effectiveness as more complex methods. However,

more complex methods have higher perfect use effectiveness than simples

methods - thus even if the average effect is similar, individual

couples can benefit from the higher effectiveness of more complex

methods. The average effect - typical use effectiveness so strongly

advocated by Trussell, has some connection with his background in

demography. But again, the typical use effectiveness can be solely on

average of two totally different populations one using the method very

effectivelly and another very uneffectivelly. In an extreme case none

in the population would use the method with the effectiveness labelled

as "typical use effectiveness".

4) I am not arguing against "use effectiveness" in general - I am only

saying that we need more insight into the existing heterogeneity or if

there is any. However, transcultural extrapolations on use

effectiveness can be pretty misleading.

Mikolajczyk

Fehring, wrote:

Sheila:

The problem is that the simple systems of NFP are just as effective (to

help couples avoid pregnancy) as the more complex systems. There needs

to be a compelling reason to use more complex NFP systems. I believe

there are for special cases, but if we wish to reach many couples --

acceptability, accessibility, accuracy, and simplicity are essential.

Keep California Safe, Free, and Holy

J. Fehring