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Sorting out contraception, natural and otherwise

I am an obstetrician-gynecologist specializing in the care of women with high-risk pregnancies. I am also a practicing Roman Catholic who has been married for nearly 43 years. It is from these two perspectives that I reflect on the misplaced controversy over proposed federal mandates on insurance coverage for contraceptives.

There is an important distinction, but it is about how various forms of birth control work — not whether insurance should cover them. Some contraceptives keep an egg from being fertilized. Other methods keep a fertilized egg from developing. For Catholics and others who believe that life (or ensoulment) begins at fertilization, this second kind of contraceptive is likely to be unacceptable — if the patients understand how they work.

But contraceptive methods that prevent fertilization itself — including one endorsed by the church — are less problematic. A majority of American Catholic women disregard the church's teachings on birth control (though the number is actually in the range of 66 to 85 percent, not the oft-cited 98 percent, which includes any Catholic woman who has ever used artificial contraception). Of course, the church bans sex outside of marriage. However, for married couples, it allows natural family planning. The encyclical Humane Vitae says, "The church teaches that it is morally permissible to take into account the natural rhythms of human fertility and to have coitus only during the infertile times in order to regulate conception."

During the menstrual cycle, there are approximately 72 hours when a woman can get pregnant. (Sperm survives for approximately 24 hours and the unfertilized egg for approximately 48 hours). Just before ovulation, the mucus at the mouth of the womb changes from thick to thin and watery. So to use this natural method of contraception, a woman is supposed to tease some mucus from her vagina using tissue paper, assess it and abstain when the mucus is thin and watery. The "natural" part of "natural family planning" seems somehow lost in all of that.

Why does the church allow a technique that takes advantage of the science of the influence of estrogen and progesterone on cervical mucus and ovulation and then extracts serial samples of cervical mucus to determine when sex without fear of pregnancy is safe?

Among artificial contraceptive techniques, there is a fairly clear separation that can be made between those that act exclusively or nearly exclusively prior to fertilization or prevent ovulation (for example, contraceptive foam, condoms, diaphragms and combined oral contraceptive pills), and those that act in part or entirely after fertilization has occurred (intrauterine contraceptive devices — IUDs — and the morning-after pill).

For that reason, I have challenged the manufacturers of IUDs and the morning-after pill and those agencies that endorse them, including the American College of Obstetricians and Gynecologists, to take care to ensure that patients considering these techniques are made aware of the mechanisms of action of these methods. Over-the-counter dispensing of the morning-after pill (Plan B) is unlikely to be associated with adequate informed consent.

Further challenging the informed-consent process, the ACOG has unilaterally defined the word "conception" to mean the implantation of a fertilized ovum into the uterus — an event that occurs approximately seven days after fertilization. This is in sharp contrast to the near-universal understanding that conception is a synonym for fertilization. Using the ACOG definition of conception when counseling in the clinical arena is apt to confuse or obfuscate the informed-consent process when a technique is said to work "prior to conception." I and others have encouraged ACOG to abandon this little-used and potentially misleading definition.

The church fails to persuade me that a true moral difference exists between natural family planning and other techniques of contraception that prevent fertilization. But in keeping with the church's teaching on the soul, I do not endorse methods that work after fertilization has already occurred.

These important distinctions are among the valid reasons why the debate about governmental mandates should continue. But those who suggest that they are defending the rights of the majority of Catholic women largely are not. I hope that the leaders of the church continue to examine these issues.

Dr. Joseph A. Spinnato II is a fellow of the American College of Obstetricians and Gynecologists. He is board certified in obstetrics and gynecology and maternal fetal medicine. He lives in Madeira Beach.

Sorting out contraception, natural and otherwise 03/04/12 [Last modified: Sunday, March 4, 2012 3:30am]
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