Natural family planning (NFP) ?can never really be safe?, said a recent headline, commenting on new research. But practitioners dismiss these findings. Does NFP work? The Tablet?s executive editor investigates.

RHYTHM AND BLUES was one headline prompted by a recent article in the British Medical Journal which indicated that natural methods of family planning could not work because there are such wide variations in the time when a woman can become pregnant during the month. The article, by Wilcox et al., declared: There are few days in the menstrual cycle during which some women are not potentially capable of becoming pregnant.

Practitioners of Natural Family Planning brushed this study aside, pointing out that it was concerned with the old-fashioned calendar method of predicting fertility which has long since been replaced with far more sophisticated methods based on temperature, the monitoring of mucus and urine tests. It is interesting that the Family Planning Association ? usually the b?te noire of the Catholic lobby ? issued a statement on the BMJ article which took a similar view to that of the NFP practitioners.

Wherever one stands in the moral debate over contraception, it is indisputable that NFP is not what it used to be. Modern methods, if practised correctly, do appear to work. Success rates quoted by practitioners are in the high nineties in percentage terms; equivalent to condoms and almost as high as the Pill. Another change is that NFP is no longer a Catholic preserve. A survey carried out in 1998 by Fertility UK, the NFP service of the Catholic agency Marriage Care, found that only 12 per cent of their clients cited their Catholicism as their main reason for using NFP. Another 58 per cent who chose NFP, some of whom were Catholics, explained that they simply did not like other methods. Twenty-two per cent cited health reasons and eight per cent religious views which were not Catholic.

Another study carried out in the United Kingdom in the mid-1980s showed that 31 per cent of those using a modern method of NFP were also using barrier methods of contraception during the fertile times.

So what are the modern methods of NFP? There are a variety of schools of thought worldwide; in Britain the most popular are the sympto-thermal method, the Billings Method and a hormone monitoring kit called Persona, which only works with regular cycles between 23 and 35 days. The sympto-thermal method requires the woman to take her waking temperature and chart it, along with observing the changes in the healthy mucus which appears most days at the vaginal entrance. The Billings Method relies on the observance of mucus alone. Persona uses urine tests to monitor hormone changes. The idea is that couples restrict sexual intercourse to their infertile days ? the number depends on which method is being used and the length of the menstrual cycle. According to the Billings Method, for example, 50 per cent of an average or short cycle is available for intercourse.

The subtle differences between the providers of these various methods could be observed at a recent study day held in London by Fertility UK. This NFP provider of the Catholic Marriage Care organisation, funded by the Department of Health, gives training in NFP to health professionals, many of whom are not Catholic. The idea that couples might use condoms on their fertile days was discussed at the study day, and many of the NFP teachers who attended the day were also prepared to give information to their clients about contraception.

But some other participants in the event, whose promotion of NFP was driven by their Catholic faith, looked on with some distaste as one speaker showed slides of demonstrating condoms in Romania. The Billings method is the one most identified with the Catholic Church, although religion is not brought into the teaching and it is made available to all ? even to unmarried couples. Billings was not discussed in detail at the Marriage Care study day, which focused on the sympto-thermal method and on Persona. Persona has been heavily and expensively marketed (it is produced by the major diagnostics company Unipath) and has also been exhaustively tested. It is sold as a modern method of family planning for health-conscious young couples. German television advertisements for Persona show gorgeous young things in fashionable nightwear having a flirty time in the bedroom. A Dutch study showed Persona Woman to be in a steady relationship, highly educated, with an above-average income; someone who wants a contraceptive method with no side effects.

The idea which links all these modern methods of NFP is that of using one?s sexuality in harmony with nature. This is an idea which would appeal to anyone ? particularly those who do not want to use drugs to stifle their menstrual cycles or mess around with bits of latex at their most romantic moments.

But what is it like to use NFP? An advertisement in The Tablet produced a number of individuals and couples who were happy to tell me about their experiences with NFP. The sample was, admittedly, skewed in that interviewees were mainly Catholic Tablet readers. But even they had very different experiences to report.

Jim, who is now in his 50s and has two children, swears by the sympto-thermal method. Abstinence is part of the real world as well as pleasure, he told me. The beauty of NFP is that both husband and wife have to practise joint responsibility for the family. There are no pills, no ointments, no bits of latex, no surgery. There is an enormous joy about the process. It is also so unbelievably sexy! Every session of making love is like total ecstasy after having had to wait for it. He went on to say that NFP had taught him and his wife to be counter-cultural.

John, who works for a computer company in Canada and is in his 40s and has four children, is equally positive about NFP. He and his wife used it to space their children, and now continue to use it to avoid having any more. Other methods of family planning take sex for granted, he told me. This one makes it very special. It takes two people to do this, so it is something they fully share. He explained that NFP forces couples to use other ways to express their affection during the fertile times, such as giving each other a hug or going out for dinner. This gives a real grounding to the relationship, he said. When asked whether it was frustrating, he replied: Studies show that people who can delay satisfaction in any area of their lives are more likely to be successful in whatever they do.

But, I asked him, what about those people who are not motivated enough to make NFP work, who find it hard to delay sexual satisfaction? Should the Catholic Church be forcing those people to use a method which does not suit their personalities? What the Church is trying to do is say: ?Here are the guidelines?, Jim answered. The Church challenges people with the ultimate. Jesus knows we can?t be perfect because we are human, and that sometimes we fail but we should not give up trying to be better in our marriages. The Church offered ideals, he said, and this could be seen as one of them.

But the distinction between ideal and reality can be little comfort to those who find it impossible to make NFP work. Susan, who is in her 40s, has three children. She and her husband used the sympto-thermal method early in their marriage. At that point it would not have been the end of the world if I had fallen pregnant, she told me. The crunch came after my third child, and I did not want to have any more. I was exhausted. The whole issue caused a crisis in our marriage.

She explained that with three children, the time which she and her husband had to themselves was very limited. The notion of planning to make love at the right time was unrealistic. We could only do it on ten days of the month, and that was not always when we felt like it, she said. And I never felt totally confident that I would not get pregnant. There was always anxiety in the back of my mind and that is not good for a relationship.

In the end, and after much painful heart-searching, she and her husband realised that they had been making the Church?s teaching on contraception more important than the health of their marriage. So they decided to use a method of contraception. Our life has changed for the better, she said. I feel now that we are able to relax and enjoy each other.

Sandra is a devout Catholic who likes the idea of NFP and believes that it can enhance communication between the couple, and encourage partnership in managing fertility. But for her and her husband, a principled agnostic, attempting to use NFP in the early part of their marriage presented insurmountable difficulties. A serious illness first showed up on her honeymoon, and went on to disrupt her menstrual cycles which lasted anything from 30 to 90 days. She carried on using NFP with the help of an instructor. My husband did not like waiting in the bedroom while I was talking to the instructor on the telephone, she told me. Her husband lost faith in NFP, particularly after they had an unplanned child. To have another child within a year would have posed a serious risk to Sandra?s health, so they abstained from sex for a year. After a few years, they had another child.

Eventually, after much searching of her conscience, Sandra decided to use contraception. What is the most important thing? Sticking to the rules and damaging a marriage or putting the relationship first?, she said. What would Christ do? She and her husband now use condoms during the fertile period. I decided it was not right to burden him with all this, she told me. He has done his best and it is just not fair; this has caused so much trouble. She acknowledges, however, that NFP is not solely to blame for this trouble; the fact that she is a Catholic and her husband is agnostic was bound to cause a problem somewhere. But Sandra feels easy in her conscience now. My husband and I have done all we could do to live according to Catholic teaching. If, in the eyes of the Church, my husband and I are ?one flesh?, his principled views have to be taken into account.

Does that teaching make theological sense? One man, a devoted Catholic who found that, some years ago, the old-fashioned method of NFP destroyed the physical side of his relationship so that he turned to contraception, told me: Ethically, the difference between NFP and contraception is so small. Why are we bothering about it? This is actually a debate about church authority.

Whether a couple uses NFP or contraception, he points out, the intention is the same: to make love without producing a child. The Catholic Church?s argument is that NFP is open to life whereas artificial methods are not. But this is where double-speak creeps in. Advocates of NFP say that it is as effective in preventing pregnancy as contraception. If so, how is it any more open to life? Either it works or it does not.

The evidence which is available indicates that if used correctly, modern methods of NFP do work. But to say that NFP works is to assume that the couple are highly motivated, organised enough to measure symptoms and keep charts every day, and that they find that limiting their love-making to certain times in the month does not damage their relationship by causing undue frustration.

But there are many couples who do not fit that mould. Church authorities would argue that they must practise more self-control. But others might reply that some couples don?t fit that mould because their personalities are not suited to it. Because their relationship is especially physical and passionate. Because they have been created differently by God.

For some couples, NFP is a joy. Others describe it as a destructive burden. Should the latter group be told there is something wrong with them, and that they should try to change so as to conform happily with church teaching on birth control? Or should they just concentrate on continuing their joyful and fruitful relationships in their own way? More than 30 years after Humanae Vitae, the time is overdue for another look at that one.

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