I read The Birth-Control Riddle by Melinda Beck, published today in The Wall Street Journal with interest and frustration.  As a veteran pro-choice sexual and reproductive health advocate, I’ve spent decades contemplating this “riddle”. I have two specific comments in response to the piece, and a few suggestions for potential follow-up stories.
 1) I find it discouraging, but understandable, that the article failed even to mention fertility awareness based methods (FABM) of birth control, which when taught so that women/couples can use the method effectively and confidently have a 99.4% effectiveness rate. Don’t take my word for it. The German study called: The effectiveness of a fertility awareness based methods to avoid pregnancy in relation to a couple’s sexual behaviour during the fertile time: a prospective longitudinal study was published in the prestigious journal Human Reproduction in late 2007. 

In addition to the typical North American dismissiveness (by healthcare providers) of FABM as ineffective, is the dismissive response given to North American women who express an interest in learning FABM.  A quick google search or a week’s hits on a google news alert for “Fertility Awareness” (the secular, pro-choice variation of the religiously contextualized Natural Family Planning) quickly establishes the burgeoning interest and use of these methods by young American women. Why is this so readily ignored by the mainstream sexual and reproductive health community (of which I am a part)? I have been mulling over this question for years. I have arrived at several answers. How I would love to see a journalist, any journalist, start asking this question.

 2) My second comment is that this article is a missed opportunity. It is useless merely to list (yet again) the birth control “choices” available to women, as if just knowing about these methods of contraception should make the problem of unintended pregnancy go away. Of one thing we can all be certain: it can’t and it won’t. What this piece lacks is any attempt to explore in depth the writer’s accurate but unexamined statement – Why are the numbers so high? The answer is a complex tangle of cultural, religious, behavioral, educational and economic factors.  Why not make an effort to get to the bottom of the so-called birth control riddle?  

Should Beck be interested in continuing to write about this issue, one angle she might consider exploring is barriers to access to information, support and services for women seeking to use non-hormonal methods of birth control effectively and confidently, including diaphragms, cervical caps and fertility awareness based methods. This is a huge issue of concern to me and the many women who can’t, won’t or don’t want to use hormonal birth control.

I have a theory that a good number of unintended pregnancies happen because women are finding little or no support to access and effectively use non-hormonal methods. Yet this lack of support is not enough to keep them on the pill, patch or ring, or to agree to submit to invasive shots or implants.  Therefore, care providers’ dismissal of young women’s requests for non-hormonal methods may actually be the cause of some of the unintended pregnancies we seem to be so puzzled by. Another issue not being talked about is that some women are getting pregnant while using the pill, patch or ring. These unintended pregnancies, which oddly don’t seem to pull down the “typical use” effectiveness rate of these methods, is partly behind the growing interest in IUDs.  The other reason IUDs are growing in popularity is backlash against traditional hormonal methods.

Another story idea is to question the hierarchy with which contraceptive methods are presented. As illustrated by Beck’s contraceptive method list, hormonal methods are always at the top, suggesting that these methods are always superior choices (that is how they are usually presented – to young women especially) even if for many women they are not. What if we presented birth control methods as three distinct sets of choices that all women and sexual health care providers should be equally knowledgeable about, and – in the case of the healthcare provider – supportive of? These method groups – alphabetically identified as barrier, hormonal and natural methods – could be presented as equally valid choices based on what suits best a woman’s needs, health concerns and values. After all, the old adage states that the best kind of birth control is one that you will use.

I am always amazed at young women’s perception that only hormonal methods are truly effective, and anything else is second best. Wherever did they get this idea? And with this impression, how possibly can they hope to be successful using other methods?  The challenge is that if we present these method groups as equally effective and worthy of choice, then we are going to have to find better ways to provide information, training and support so that women and their partners can use all of them with confidence.  

Included in any discussion about contraceptive methods would be strategies for moving effectively and confidently between method groups as our health and fertility needs change across our reproductive lives. This latter would require caerful evaluation of our sexual decision-making skills. One of my major concerns with the over-reliance on hormonal birth control is the mindset young men and women develop around 24/7 sexual availability, or what I call “mindless sexuality.”  It is time to reconnect our minds and bodies, and to align sexual activity with all of its potential benefits and outcomes including fun, pleasure, relational connection, STIs and pregnancy.

Yes, birth control continues to pose a riddle. But ask yourself this. If what women (and their partners) are being offered to prevent unintended pregnancy is so effective, attractive, acceptable, comprehensive and available, then what is going on here? Could it be that what women are being offered is NOT as effective, attractive, acceptable, comprehensive or available as this article would have us believe?

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