Kirsten Antonacci Dempsey, MA

A LENS OF MUTUAL LEARNING

As new literature arises on controversial topics in Catholic health care like contraception and natural family planning (NFP), it is helpful to use a particular lens to elucidate positive takeaways from different viewpoints. Julie Rubio provides such a lens in her 2005 article, "Beyond the Liberal-Conservative Divide on Contraception: The Wisdom of Practitioners of Natural Family Planning and Artificial Birth Control," where she examines Humanae Vitae alongside the experiences and arguments of advocates on both sides to search for common grounds.¹ By promoting an understanding of reasons why each side uses their respective methods, Rubio establishes a lens of mutual learning from which to evaluate the methods themselves. Rubio's hope "is that bringing the distinctive experiential wisdom of both groups into relief and exploring the common ground that both sides share will make room both for respectful agreement and mutual correction."² This approach seems capable of bridging divides and fostering fruitful conversations. This is especially valuable in Catholic health care given the moral commitments to abide by the Ethical and Religious Directives amid diverse religious, political, and social views among the employees who work for, and patients who receive care at, Catholic institutions. This lens of mutual learning can aid ethicists, clinicians, and others in Catholic health care to meaningfully engage with new research arising in both the contraceptive and NFP literature. Using Rubio's approach, I will examine two recent works from these literature circles and suggest how each can learn from the other.

RECENT NFP LITERATURE

Unseld, Matthias, Elisabeth Rötzer, Roman Weigl, Eva K. Masel, and Michael D. Manhart. 2017. "Use of Natural Family Planning (NFP) and Its Effects on Couple Relationships and Sexual Satisfaction: A Multi-Country Survey of NFP Users from US and Europe." Frontiers in Public Health 5 (42). doi:10.3389/fpubh.2017.00042.

Unseld, Rötzer, Masel, and Manhart (2017) conducted a multi-country survey to examine effects of NFP on couple's relationships and sexual satisfaction. Two online questionnaires were created, for women and men respectively, translated from German to English, Polish, Italian, Czech, and Slovak, and then distributed to all current email addresses of two major NFP organizations in the US (Couple to Couple League, CCL) and Europe (Institut für Natürliche Empfängnisregelung, INER), which teach the symptom-thermal method (involves cervical mucus observation combined with temperature). A total of 2,560 respondents completed the questionnaire between February and April 2015, with 32.4% U.S. respondents and 43.7% European respondents, 77% female and 23% male. Most were married (89%), well-educated (73% hold a university degree), and described their financial status as "good" (46%) or "very good" (19%). Average NFP use was 8.5 years (+/- 8 years), and 80% of the 95% who reported using NFP use sympto- thermal method. Users learned their method from a trained NFP counselor (74%) and/or by reading an NFP book (54%).

The authors surveyed four effects of NFP on relationship dynamics: gaining knowledge of one's body, developing one's relationship, valuing partner's interest in NFP, and explaining sexuality to children. Ninety-five percent of women and 55% of men said using NFP has improved knowledge of one's body. Among first year users, 92% (n = 297) affirmed this. Majorities of men (74%) and women (65%) stated NFP use improved their relationship and the authors found that education level did not impact this improvement. Regarding partner involvement in NFP, 94% of women and 96% of men felt their partner's interest is either "very important" or "important." For respondents with children, over 80% of respondents indicated the knowledge gained by using NFP helped them explain sexuality to their children.

The survey then examined five effects of NFP on sex life: speaking about sexuality in one's relationship, enjoying sex life, improving knowledge and understanding of sexuality, frequency of sex, and satisfaction rates with frequency. Most women (69%) and men (72%) pronounced that NFP enhanced their ability to discuss sexuality with their partner. Over 80% of respondents stated NFP improved their knowledge and understanding of sexuality, again without education level impacting responses. Of respondents in a relationship, approximately 62% of all respondents said NFP improved their sex life overall. Regarding frequency, men and women responded similarly, with almost half indicating they have sex four or more times per month. Seventy-five percent of women and 73% of men said they were "satisfied" or "very satisfied" with their frequency of sex.

This survey provides valuable insights on the experience of NFP users. The authors' results reflect former studies, like VandeVusse (2003), Fehring (2016), and Oddens (1999). However, their work expands on earlier studies because they have a larger and geographically diverse respondent size of over 2,500 individuals from seven different countries, thus enhancing generalizability across countries and cultures. Their study is limited, as the authors acknowledge, by the respondents' profile reflecting generally married, well- educated, and financially secure individuals, which may limit generalizability to non- married, less well-educated, and/or less financially stable individuals.

RECENT CONTRACEPTION LITERATURE

Bitzer, Johannes, Victor Marin, and Josefina Lira. 2017. "Contraceptive counselling and care: a personalized interactive approach." The European Journal of Contraception & Reproductive Health Care 22 (6): 418-423.

Bitzer, Marin, and Lira (2017) discuss studies on deficiencies in contraceptive counseling and care (CCC) and respond with an approach to CCC that improves shared decision-making by tailoring contraception to each individual. Examining European and global studies, the authors organize gaps and deficiencies into four issues. First, healthcare providers (HCPs) seldom listen to patient concerns and lack patient-centered communication skills. For instance, HCPs generally guide discussions about contraception with little room for patients to express their opinions. Second, HCPs often lack time to take sexual and reproductive health histories, given that consultations are frequently reported to be around five minutes. Third, HCPs lack knowledge and training about methods and guidelines for use and safe prescribing.

Studies reveal that patients often receive outdated, erroneous information about method characteristics, risks, and benefits, which the authors suggest may result from insufficient education on contraception in obstetrics and gynecology residency programs. Fourth, HCPs commonly dominate clinical interactions and do not meaningfully involve users in decision-making, with method selection largely depending on provider preference. These issues impact selection of methods appropriate to a patient's biopsychosocial (BPS) profile, goals, and values, which can then affect adherence.³

In response to the above weaknesses, the authors seek to develop a holistic approach to CCC by utilizing literature standards and the concept of interactive shared decision-making. They identify three elements of good CCC: 1) building a trustful relationship, 2) informing, educating, and empowering women/ couples regarding their sexual and reproductive health, and 3) helping women/couples to choose or change a method to best fit their needs, values, and BPS profile. The authors clearly and thoughtfully describe behavioral characteristics and practices that build trust with patients, like active listening and inviting questions. To the second element, their goal is for the woman/couple to know and understand how each method works, and what its efficacy, risks, benefits, and side effects are such that the patient becomes expert on the method and the method becomes 'her/their own.'

Regarding method selection, the authors outline a five-step approach for counselors to use: 1) Listen to patients' needs, priorities, and values, and exclude methods that do not meet them, 2) Assess patients' BPS profiles and exclude methods based on medical and psychological criteria, 3) Look for possible benefits of remaining methods, 4) Show the benefit/risk ratio of available methods and foster shared decision-making, and 5) Accompany the woman through follow-up visits and proactive discussions to ensure safe, effective use. Ultimately, the three elements correspond with literature revealing positive impacts from patient-centered care, relationship-building, and shared decision- making. The authors' straightforward approach to address current counseling deficiencies contributes to the ongoing research for more personalized, holistic approaches to family planning counseling.⁴

MUTUAL LEARNING

To encourage mutual learning among these articles, Rubio's approach involves first examining common grounds. One point is a common interest in counseling strategies that involve shared decision-making between HCP and patients. Bitzer et al. work toward this by outlining a new approach for counseling. Unseld et al. see this reflected in satisfaction of users with NFP methods and positive reports on relational and sexual questions. Another point is the common interest in promoting knowledge and understanding of one's method. Bitzer et al. encourage this through their interactive, personalized approach to counseling to find a method best suited to a patient's needs, values, and BPS profile. Unseld et al. find NFP users experiencing an improved understanding of their sexuality, their bodies, and satisfaction with their method, suggesting that NFP counselors are utilizing a shared, personalized approach to counseling.

Having examined some common grounds, each side can proceed to learn from the other. The contraception literature on holistic counseling strategies is more abundant than the NFP literature, which is only mentioned briefly in articles describing NFP methods. NFP literature could expand research in this area. Conversely, Unseld et al.'s article reveals affirmations of NFP methods' positive impact on some of the very deficiencies identified in CCC literature. For instance, if NFP users report improvements on relationship and sexual factors, then NFP counselors are likely listening and responding to patient needs, priorities, and values that affect these factors. If NFP users are more knowledgeable about their bodies and sexuality, and feel better equipped to discuss sexuality with their partner and explain it to their children, then NFP counselors are likely informing, educating, and empowering women/ couples regarding their sexual and reproductive health. Concerning method selection, NFP counselors are typically trained in one method so their strategies to respond to women/couples' goals and values is to educate them how to use their method toward their needs or goals, such as avoiding or achieving pregnancy. NFP counselors and physicians could take Bitzer et al.'s advice to improve education on other NFP methods to enable more suitable method selection among NFP methods based on the needs, priorities, and values of each patient.

Further research among both literature circles could work to incorporate the positive takeaways from each side. Employing a lens of mutual learning can encourage this research and foster fruitful conversation among these different views. Such mutual learning can aid HCPs and counselors in improving the clinical encounter and working with patients to better understand and meet their reproductive needs, goals, values, and BPS profiles.

Kirsten Dempsey is a Ph.D. student in Theology and Health Care Ethics at the Albert Gnaegi Center for Health Care Ethics at Saint Louis University. She also works in mission and ethics with SSM Health.

kirsten.dempse[email protected]

ENDNOTES

1. Julie Hanlon Rubio, "Beyond the Liberal/Conservative Divide on Contraception: The Wisdom of Practitioners of Natural Family Planning and Artificial Birth Control," Horizons 32, no. 02 (2005): 271, accessed November 4, 2016, doi:10.1017/s0360966900002553
2. Rubio, "Beyond the Liberal/Conservative Divide on Contraception," 291.
3. A BPS profile is the collection of biomedical, psychological, social, and other factors (i.e. relational and sexual) that affect a patient's healthcare decision-making.
4. I recognize there are theological and practical challenges with referring to contraceptive counseling and family planning counseling interchangeably, but it is not in this article's scope to address them.