When considering universal health care, religious liberty, and informed consent, the topic of family planning is one which I have seen come up in practice, and which is affected by government policy. Many couples of Catholic faith as well as non-Catholic faith (for a variety of reasons) are interested in alternatives to artificial contraception; many are specifically interested in Natural Family Planning (NFP). However, as a physician I have witnessed several barriers for couples to use NFP.
The first barrier is that NFP has largely not been covered by medical insurances. As background, the Affordable Care Act (ACA), passed in 2010, in section 300gg-13 indicates that “A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for… with respect to women, such additional preventive care and screenings not described in paragraph 1.” This formed the basis of the Health and Human Services contraceptive mandate, which required all employers—including Christian organizations such as hospitals and enterprises owned or controlled by religious organizations—to provide artificial contraceptive coverage in health insurance packages. Many legal challenges ensued following this mandate, as many of these groups considered it to be at odds with their religious freedom. One of the most famous examples is the seven-year legal battle waged by the Little Sisters of the Poor, a religious order of Catholic women who provide care to the elderly poor and dying, which made it all the way to the Supreme Court before finally ending in favor of the Little Sisters in 2016.
What is lost in this legal dispute is the clear fact that, under the ACA’s section 300gg-13, NFP counseling and costs should be covered. In practice, these services are largely not covered by insurances, including government health insurances like Medicaid. This not only violates the same ACA but also violates the religious freedom of many couples. On the other hand, artificial contraception (which I personally do not currently prescribe due to religious objection as well as other concerns) is very easily available at no cost among insurances, including government insurances; in addition, promotion of artificial contraceptives is very widespread with ads and school sex ed campaigns.
“Full disclosure on the potential side effects and harms of artificial contraception use must be made available at all levels, for the benefit of marriages and women (and children and families) in general.”
In addition to this, there are other significant barriers for couples to use NFP:
Firstly, medical students are largely not trained in the counseling and use of NFP for patients.
Secondly, to my knowledge, the FDA has only approved one purely NFP protocol, Natural Cycles, despite NFP methods being safe from side effects (such as side effects seen in FDA approved artificial contraception) and as effective than the birth control pill (or more effective for particular methods of NFP, such as the Marquette model) with some reaching a typical use pregnancy rate of 2% as reported by the CDC, and perfect use rate lower than this.
But many couples would prefer NFP for a variety of reasons, both religious and otherwise.
For one, although I was not taught this in medical school and it is not widely disclosed, hormonal contraception (and others such as the copper IUD) can act as an abortifacient by preventing the implantation of the baby in the embryo stage of development onto the uterus lining (you can check any hormonal contraception here under Mechanism of Action to confirm this).
The fact that women have not been informed about this prior to starting such methods is a gross lack of informed consent by doctors and pharmaceutical companies, and a journalistic failure on the part of media. On top of that, it is a source of abortions not included in statistics.
Equally consequential is the fact that hormonal and other forms of artificial contraception have various side effects—many of which I have noted in my practice—including widespread mood changes and even depression, which are potentially harmful to marriages. Here is a review of the side effects, which include “increased risks of breast cancer, cervical cancer, inflammatory bowel disease, lupus, multiple sclerosis, cystitis, bone fractures, depression, mood disorders and suicides, fatty weight gain, and female sexual dysfunction. With the long-acting injectable contraceptives there is an increased risk of getting HIV. Misleading prescribing information regarding the risks of heart attacks, strokes and blood clotting problems were also noted.”
Interestingly, the use of NFP in marriages is associated with reduced divorce rates, and artificial contraception is associated with higher divorce rates (especially permanent sterilization) even when controlling for income and education.
The widespread use and availability of artificial contraception has, in the minds of the people, eliminated the primary deterrent for premarital sex: pregnancy (in reality, the pregnancy rate while using many of these methods is still significant, especially with typical use). This has manifested in, and enabled, the sexual revolution that started in the 1960’s, which in turn has led to an increase in premarital sex, an increase in children being raised by one parent, an increase in sexually transmitted diseases, and, finally, all the societal problems associated with these things (such as increased poverty, higher incarceration, drug abuse and school dropout rates for the children).
In a 2018 abortion surveillance, published last November, the CDC reports that “Among the 42 areas that reported by marital status for 2018, 14.8% of women who obtained an abortion were married, and 85.2% were unmarried.”
FDA approval of NFP methods is important, both to acquire medical coverage for their use and increase medical training on their use. Furthermore, full disclosure on the potential side effects and harms of artificial contraception use must be made available at all levels, for the benefit of marriages and women (and children and families) in general.
Rene Trabanino, M.D./Ph.D. practices Family Medicine in Los Angeles and is a member of the Catholic Medical Association. For more information on NFP and advocating for its coverage and education of its use, you may go to Home – FACTS (factsaboutfertility.org).
James G Hanink
Thanks, Dr. Trababino for this instructive background essay.