Natural Family Planning: Nature's Way - God's Way

45. Natural Family Planning Programs - Development and Evaluation


Several distinctive aspects of Natural Family Planning (NFP) differentiate it from other family planning techniques. Although these have been generally spoken of in the past, it is only recently that a significant theoretical contribution has been made by Thomasina Borkman, Ph.D. (1) to better conceptualize this distinctiveness. Before a discussion of NFP programs it seems appropriate to review her key concepts. Dr. Borkman defines Natural Family Planning from a sociological perspective as "a value oriented inter- personal behavioral innovation", and then analyzes some of its key characteristics. Four areas are thus underlined, namely:

1) That NFP is innovative in that it is not viewed narrowly as a method to limit or space births but more broadly as a user-controlled approach to fertility acceptance and family planning that lets couples choose to limit, space, or plan births. NFP is knowledge and not technology dependent, and therefore users can truly aspire to a relative independence or fertility autonomy. It also emphasizes knowledge and working with one's or a couple's fertility (fertility awareness) rather than relying on multiple technologies (contraception) which interfere with fertility or destroy it (sterilization).

2) NFP is interpersonal in its focus in that its major active principle, besides self-knowledge of fertility, is sexual behavior modification which requires cooperative interpersonal behavior by the couple. This aspect can be an initial deterrent or a long term reinforcer depending on how it is presented or approached and integrated by each couple.

3) Its value orientation is explicit both in its fertility objectives and in affecting the complex interpersonal sexual behavior in different cultural contexts. One can also observe how to a greater or lesser extent some major ideas and values linked with contemporary trends in ecology, preventive health, holistic and self-help groups and women's health movements are incorporated in numerous NFP value clusters. The primary NFP value cluster emphasizes the shared responsibility of the couple, the innocuity of NFP with no impingement on the physiological processes, the personal awareness of sexual and fertility processes, the self-sufficiency leading from professional and technological dependence to true autonomy, and finally the integration of sexual behavior modification or periodic abstinence, viewed as a positive element, and not just a deprivation, opening the way to possible changes in communication and role relationships often referred to as a way of life.

4) NFP is also primarily experiential in its learning principles. Knowledge competence grow more through experience (doing and practicing) than by theoretical knowledge. The emotional aspects of NFP are especially facilitated through peer influence. Therefore it has many similarities with other self-help groups such as breast feeding, natural childbirth, alcoholics anonymous, or others. Although the many facets of Natural Family Planning are viewed in the preceding chapters of the first two sections of this book, special insights into the development of NFP as a movement and its perception by various user-couples from their personal experience are expertly described in recent American reviews by Shivanadan (a) and Aguilar. (3)

In view of the above it is not surprising to meet a variety of concepts and forms of NFP programs. NFP is perceived either as a movement or a social service program developed essentially with goals of fertility regulation or even with a population control emphasis. It can be integrated as one aspect of a comprehensive family life promotion program (more often than not within a religious context or diocesan structure) or, again, it can be part of a maternal and child health, a nutritional or community development program.

Some of the key factors which significantly influence NFP program development can be summarized as follows:

The importance and value of program planning and evaluation need to be stressed both from a developmental point of view within each program and from the crucial aspects of accountability both to members of the organization and to outsiders such as the funding supporters. It is important to stress that evaluation is an essential aspect of the planning process not only in justifying project expenditures but especially to determine and evaluate special needs and problems, and to determine the most appropriate future course of action. In the field of Natural Family Planning, evaluation efforts are still very much in their infancy. These have primarily concentrated on the biomedical evaluation of NFP as a family planning method in terms of use-effectiveness but very little, if at all, on the evaluation of NFP programs.

The State of the Art

NFP Program Development: Overview Discussion

The growth of NFP programs and their expansion is of recent origin and can be traced for more than 10 or 15 years in only a few isolated instances. To better understand the many factors involved it is appropriate to discuss some aspects of NFP program development: Stages of Development: Most programs are still in their pioneer phases or that of initial implantation with very few programs having reached the second or third phase of maturation and expansion at the national level. The fact also that some programs are primarily movements and resist or hesitate in the evolution toward services or fear the loss of some of the experiential learning principles that the movement fosters is an important consideration.

Knowledge about NFP: Competent research in NFP is still very limited having few competent, motivated, and adequately funded scientists since most population research resources are currently involved primarily in contraceptives, sterilization, or abortifacient technology development or program implementation. Although some of the major biomedical parameters of the fertile period have been established, their variations in special circumstances (post-partum, post-pill, pre-menopause) remain to be established or better defined. The renewed emphasis on sexual behavior modification or periodic abstinence and the determinant role it plays in initial acceptance, continuity, and variation in use-effectiveness has just begun. Applied research in teaching technology, program characteristics concerning organization, records, follow-up, has hardly been initiated.

Rivalry in NFP Methodology: The existing rivalry between the fertility determination approaches such as the emphasis on a single index by the Ovulation Method or cervical mucus ovulation parameter only, and on the other hand, the insistence that multiple indices of fertility such as cervical mucus with cervical changes and BBT (Basal Body Temperature) should be taught to all NFP teachers in order to then make it available to all users for their choice, continues to plague the field and divide some programs, workers, and leaders. This is especially wasteful of human and other resources at program, national and international levels.

Religious Auspices: The fact that at this point the majority of programs are under specific Catholic or diocesan structure may impair and probably limits in some cases the access of NFP to potentially interested persons of other religious persuasion. In several countries this is perceived as a necessity at least initially to provide both legitimation, resources and manpower. In several countries it has not prevented NFP users to be over half non-Catholics. A progressively increasing number of non-Catholics are interested in NFP and NFP program development.

Relationships to Governments: This is often closely tied to that of private national or international Family Planning Associations who have dominated the recent governmental involvement in family planning services both nationally and abroad. The situation varies greatly in each country based on a host of factors. it is especially important in the United States which finances more than half of all foreign aid in family planning and where many scientific and development programs originate.

Funding: This issue is very closely tied to governmental influence. The fact that in the last 20 years (from the 1979 Sri Lanka UN Population Conference) the annual international population assistance increased from $2,000,000 (US) in 1960 to approximately $400,000,000 (US) in 1979 might give one an idea of the financial drive in family planning and population programs. One of the priorities, no doubt is to insure a more equitable distribution of these resources to NFP programs, which are currently supported primarily by private non-governmental organizations (a large number are Catholic development organizations). Progressively, in addition to some governmental support to national NFP programs as in France, Canada, Australia, New Zealand, United States, England, Kenya, Liberia, and Sierra Leone, a few governments have begun to support the international development efforts in NFP programs. This includes those from Canada, Germany, England, USA, and France. Quality NFP programs become an increasing priority to ensure accountability not only to the funding agencies but also to the NFP users themselves.

NFP Program Development: Initiatives

NFP program development efforts can be considered under the following three categories: (1) information sharing; (2) applied research; (3) special development programs.

Information Sharing - This has been the major form of program development of the last 20 years whereby consultants from earlier programs visited interested groups and countries or vice-versa, and shared their expertise with colleagues and other countries. During the last ten years these have been formalized through NFP training congresses or seminars such as those held by the Human Life Center in Collegeville, Minnesota (USA); those by CLER (Centre de Liaison des Equipes de Recherches) at Poissy near Paris (France); the Ovulation Method Institute now regularly held in Los Angeles, California. A large number of the more developed national programs also hold regular annual meetings with or without scientific meetings and publish their own newsletters and teaching materials. In the last five or six years various governments and even the World Health Organization have facilitated and supported these and even instituted assistance such as exchange and training scholarships.

In 1974 and 1977 respectively two international NFP Associations were created: The International Federation for Family Life Promotion (IFFLP), with members in 70 countries and some 50 structured national organizations in 40 countries. Its primary interest is to help to develop national organizations interested in family life promotion in general and Natural Family Planning in particular; The World Organization of the Ovulation Method - Billings (WOOMB) whose main goal is the certification of teachers in the Billings Ovulation Method and monitoring the standards of teaching in those areas of the world where the Billings method has been introduced.

These two organizations have contributed significantly to the increased sharing of NFP program information and the rapid growth of NFP expertise.

Applied Research - Major applied research efforts can be outlined under the following:

* Biomedical Research, towards the improvement of our knowledge of NFP, whether through effectiveness studies or major refinements in ovulation parameters. These for the most part are described in the earlier research section and date back only 10 or 15 years.

* Programmatic Research, in addition to special individual program efforts producing their teaching aids and developing training tools, special mention of two general categories of research efforts should be described:

Special Development Programs - Most NFP programs have grown through informal NFP knowledge sharing meetings and exchange of visits described earlier. During the last few years two major new categories of organized NFP program development efforts have taken place either from a strong financial support of national expansion efforts or from broad implantation efforts at a continental level. A few words of description on each category are indicated as follows:

a) Major National Expansion Efforts - of the significant national expansion efforts currently underway in several developing countries, a couple are worthy of comments, such as:

The Family Life Promotion Program (Carvajal-Misereor), is under the sponsorship of both the Fundacion Carvajal and the National Episcopal Conference of Colombia, S.A. Initiated in 1975 this program focuses specifically on responsible parenthood, and the training of NFP teachers and development of services as key objectives. Its program evaluation should be forthcoming sometime in 1980-1981;

The All-India NFP Program, sponsored by the Commission for the Family of the Catholic Bishops Conference of India (CBCI), this is a two year substantial NFP expansion financed by Misereor, to be administered nationally by IGSSS (Indo German Social Service Society) and implemented by the local diocesan delegate agencies. This NFP service expansion program has been operational since 1978 with a growth from eight programs in January 1978 to over 59 programs by early 1980.

b) Multinational NFP Development Efforts - The "African Life

and NFP Instructor Training Project" is a major on-going NFP development program administered by the International Federation for Family Life Promotion and financed by various development agencies and governments. The process is essentially one of accelerated NFP program development by the use of initial site visits, by IFFLP consultants, followed by NFP and Family Life Education Training Workshops where interest is present and this will be followed by a major Trainers' Workshop scheduled for the fall of 1981 to train NFP program leaders. More than 20 African countries are involved.

NFP Program Evaluation

Although this is the last aspect to be discussed, it is no doubt among the most important, and one that will strongly influence the future of the NFP movement. This discussion is complex by the fact that in many countries NFP still is considered more of a movement than a service, rendering its evaluation and accountability far more difficult. However, with the progressive increase in resources available for NFP services, increased needs for accountability, program planning and evaluation are becoming more evident. It appears important to elaborate here on three pertinent areas, namely:

Programmatic Knowledge - In order to better develop or plan NFP programs or to evaluate on-going ones, special understanding of program administration or evaluation principles should be integrated. The basic structure, organization and policies of programs should be considered along with measurements and/or estimates, efforts and costs of efforts for the three basic components of any program -

Resources Clients Fiscal
Staff, Data-Intake, Income
Services, Follow-up Expenses
Time, etc.

The evaluation must extend beyond efforts and costs (activity report) to whether the actual program accomplishments or client outcomes match with initial program objectives. Such efforts at accountability require a minimal management information system on these three components. (4)

In the last 10 years two or three academic centers in the USA have concentrated in adapting such program administration principles to family planning and population programs and their evaluation manuals should be on the book shelf of any serious NFP program administrator or evaluator. (5,6)

NFP Program Evaluation initiatives - It is important that family planning program evaluation principles be appropriately adapted and applied to NFP programs, with a full understanding of the distinctive aspects of the latter as specified by Thomasina Borkman. In addition to the major Australian NFP survey (Johnston et a1. (7) which concentrated primarily on NFP method comparison rather than program elements, a few program evaluation projects are now under way or about to begin. The recent report from Dr. Kathleen Dorairaj of the Indian Social institute, in New Delhi, as one of the four regional commissioned evaluations brings such an insight to the large All-India program supported by Misereor. (8) Similarly in 1980 and 1981 the evaluation reports on the two national NFP programs of Colombia and Mauritius are expected to be available.

New NFP Program Guidelines - In addition to the existing informal NFP program guidelines it is pertinent to refer here to recent efforts of the Human Life and Natural Family Planning Foundation in producing a "Handbook of Operating Procedures for NFP Programs" which it is hoped shall soon be published and available to the public by the US Government. (9) New initiatives in this area are urgently needed.

Efforts should be undertaken not only to better adapt NFP program criteria to the international scene and the variety of NFP programs but also to incorporate some of the distinctive aspects of NFP which Borkman underlines, such as self-knowledge, interpersonal communication between spouses, fertility management or autonomy, and areas of family functioning in general.


This section presents a summary of the State of the Art in NFP program development. Only an overview and initial insight are provided here as most of the developing program experience remains buried in the field.

With an increase in both private and public funding of NFP programs and the increasing demand for accountability, program planning, and evaluation are beginning to surface as crucial issues, and this will surely influence the future development of NFP programs.


by Claude A. Lanctot, M.D., MPH
Executive Director of IFFLP

Office for Family Planning HHS (Health/Hurnan Services) "Operational Guidelines and Procedures for Natural Family Planning Programs"; developed by Dr. M.C. Martin of the Human Life/NFP Foundation, under U.S. Government contract to provide guidance to NFP programs. Can be obtained directly from: Office of Family Planning (US Government), 5600 Fishers Lane Rm. 749, Rockville, MD 20857 (USA).

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