Family Planning: A Reality Check for Global Midwives
by Robin Lim, CPM & Marie Zenack, Master Teacher of OM

[Editor's note: This article first appeared in Midwifery Today Issue 55, Autumn 2000.]

Working overseas presents multi-layered challenges to those of us devoted to healing birth. The first time I witnessed birth in an Indonesian hospital, I was devastated. But the details of what I saw at Sangla Hospital in Denpasar, Bali, that night do not haunt me tonight. What does haunt me is the fact that the misogynistic obstetric protocols I witnessed being routinely used there originated in the United States. Cuban midwife Marina Alzugaray recently said to me, "It was Western civilization that ripped off the indigenous birth practices of the world. It is now up to the midwives of the West to promote the healing of birth globally."

For years I worked to heal birth in Bali. With healer priests and priestesses, I studied the Lontar—the holy books of Hinduism—with regard to pregnancy, birth, postpartum and childrearing. Hand in hand with expectant families, I strove to return birth to the holiness it once enjoyed in Bali before the advent of Western style hospitals and clinics, while I worked to lower the all too real risks by promoting a gentle midwifery model of care. I found myself failing these families in the postpartum period, a time I had so honored in my work both as a midwife and an author.

In the precious postpartum time couples would ask me, "What about family planning?" and it was then that I fell down. I lost the magic. I was without an answer that worked for me, let alone for these village people. My medicine bag was not yet full.

I must first explain what Indonesian women face in the way of "keluarga berancana" (family planning). The Indonesian government has ordained that its people must live by the motto "dua anak cekup" (two children enough). I know of no family that has been punished for having three or more children. Indeed as one travels to the more remote areas of the outer islands, the families are still larger. Many, many Indonesians, however, fear their government will one day dole out retribution on non-compliant families and their villages.

In this setting women are fitted with IUDs that have no string, making removal a difficult medical procedure that is far too expensive for the average Indonesian family. Under the threat of tyranny, health providers inject Depo-Provera into women, assuring them there are no side effects. Norplant is inserted in women who will not be able to find a healthcare provider to remove it, even if the side effects are ruining their lives. Birth control pill users are not screened for high blood pressure. They are told, "no problem" when they inquire about potential side effects. Perhaps the most heartbreaking side effect of the pharmaceutical methods of birth control is the difficulty couples have conceiving after using the pill, Depo-Provera, Norplant and the IUD.

I could go on, but my intent is not to dwell on the problem but to suggest a viable solution. First of all we midwives must understand the difference between birth control and family planning. Family planning involves choice. Family planning does not harm the health and well being of anyone. Family planning is reversible, meaning it can be used to postpone or achieve pregnancy. Family planning respects the divinity of the fertile process.

Birth control (emphasis on "control") in the form of pharmaceuticals can and does put a woman's health, and even her life, at risk. Often in settings outside the West the pill, Depo Provera, and Norplant have resulted in sterility without women's consent. Other, less-known methods have been used to the same end, like a vaccine that marries human chorionic gonadotropin (HCG) and tetanus and has been administered five times over a period of one year to school girls and women aged twelve to forty-nine in the Philippines, Nicaragua, Mexico, Indonesia, and other nations, resulting in lifetime infertility (1, 2). Where is a woman's choice in this setting? And where, I ask, is the respect for our God-given gift of fertility? All too often couples who cannot possibly feed more children choose celibacy over the risks of the artificial methods of birth control. However, as in Indonesia where trusted health providers are inspired to lie about side effects, women get hurt, women become sterile, and women die, never knowing how or why.

The "why" is simple. During the Nixon administration Henry Kissinger penned a bill called "U.S. Security Memorandum 200." He argued that rapid population growth could lead to unrest, which would threaten U.S. access to poor countries' mineral resources and lead to expropriation of foreign investment. "In order to control the resources of the developing nations, we must first control their populations" (3). So you see, the very comfortable lifestyle of many, many Americans has a price, and it is paid for by innocent people in faraway countries.

In order to serve as a midwife, from a global perspective, we must find viable answers to the inevitable postpartum questions, How about family planning? How can we limit the number of children we have, without risks to our health, both spiritual and physical? Are there effective methods of family planning that are safe for breastfeeding families?

If your answers all involve the need for healthcare providers and pharmaceuticals, the people who trust you are in trouble. Self sufficiency is a must in today's changing world. Remember there are many, many communities around the world where clean water, necessary when using a diaphragm or cervical cap, is not easily available. How effective do you think barrier methods will be when the couples run out of spermicide and have no money to buy more, even if they can find a place to purchase it? Also, in some cultural settings women are not allowed to insert anything into their own yonis (vaginas).

When the Indonesian economy collapsed and a despot who ruled for over thirty years fell from power, the pharmacies in Bali turned away women seeking refills of the pill. These desperate women came to me for help. When I was in the Philippines I hiked to remote villages and found no pharmacies at all. I found communities with nearly no cash economy to afford artificial methods of birth control, even if villagers could make the long trip to a city.

In both cases I offered a simple solution—the Ovulation Method of Natural Family Planning, which I like to call OM. Fortunately in 1995 Marie Zenack, a wise woman and master teacher of natural family planning, made me face up to the fact that my medicine bag was only half full. She patiently instructed me and strictly tested me, until I too became a teacher of OM. Since then I have taught this method to well over four hundred couples in three countries. I have met and been blessed to work with Dr. Francesca Kearns (Sister Fran), who has taught OM in over thirty-five countries for nearly forty years. With Father Denis L. St. Marie she co-authored Teaching the Ovulation Method, Step by Step, Cycle by Cycle. In 1997, both Marie and Sister Fran came to Bali to help me train teachers of OM for Indonesia.

There are several methods of natural family planning. I prefer OM because it does not require any apparatus. A culturally appropriate charting system is necessary for the method to be effective. In Asia I found a very loose concept of personal belongings to be the norm. A woman could not expect her children not to play with a thermometer or a lens, for example. Any family member may wander off with these devices, depending upon his or her needs at the moment. Living in a small village, within a family compound, I grew accustomed to seeing my sarongs on other women in our extended Balinese family. Eventually my personal belongings would circulate back onto my shelf. However, if one is to use a family planning device daily, this would render the method ineffective. I taught OM to one couple in Bali who became pregnant with their second child, their excuse being, "We lost our pencil." In truth, they felt ready to add to their family and were delighted with the birth of a new son.

In Asia I found the concept of natural family planning easy to teach, whereas in the United States I find women are often less trusting of their own ability to observe and chart changes in their own bodies. As an Asian/American I see both sides. The Filipino grandmother in my heart says, You can trust what you see and what you feel. Your body will not lie to you. This method can work for you. But inside my mind is another voice that says, What if I can't tell the difference between wet and dry? I'll get pregnant again, and not be able to fully breastfeed this baby. I'll be afraid to make love. That will hurt my marriage. . . . Now that voice is louder than the voice of my Filipino grandmother. How do I make peace with these two distinct voices?

Even the most skeptical scientific mind will find answers in Mercedes Arzú Wilson's book, Love & Fertility. This book and the film of the same title are available from Family of the Americas Foundation (800) 443-3395. On these pages you'll find clear and concise, step by step guidance on how to avoid or achieve pregnancy naturally. In the back of the book you will find a wealth of scientific support for the Billings Ovulation Method. Please also visit the Family of the Americas Web site at www.familyplanning.net.

Here I must look at foundation beliefs. We as Americans are acculturated to certain beliefs. Women in other cultures may share some of our beliefs, but for the most part, I find they have distinct core concepts that Americans do not share. For example, in America I've found most people believe that life is normal until you have children; then it goes all askew. In Asia most of the people I came to know believe that life becomes normal once you have a baby. These clearly different perspectives shine opposite kinds of light on the issues surrounding human fertility. Ask yourself, Do I view my fertility as a curse or a gift?

Please read and re-read the book, Conscious Conception by Jeannine Parvati Baker and Frederick Baker. In these pages even those of us deeply imbued with mistrust of our bodies and our cycles can regain and rebuild a deep respect for the divine feminine and the divine masculine as it manifests in our sexuality and fertility.

References

  1. Miller, James A. Baby-killing Vaccine: Is it being stealth tested? Available online.
  2. The Human Laboratory. (1996). The Witness Series. British Broadcasting Corp.
  3. Collins, Carole J.L. (1992, Nov./Dec.) Women as hidden casualties of the Cold War. Ms. magazine.

Observing and Charting

Wet = possible fertility. Dry = infertility. Bleeding or spotting = possible fertility.

Observe what you feel and what you see outside the vagina at the vulva. Avoid internal exams. Observe all day but especially when going to the bathroom. Tissue paper is helpful for observation at the vulva. Observe before and after urination. Chart the most fertile sign of the day. Slippery wet is more fertile than simple wetness. Chart at the end of the day, before going to sleep for the night. At the beginning of each menstruation, begin a new line of charting.

  • Bleeding or spotting (blood flowing down)
  • Dry: see nothing and feel nothing (cracks in the dry ground)
  • Wet: see something or feel something (the egg that may be present.)
  • Slippery wet
  • Key day, the last day of slippery wet
  • Dry but still fertile
  • Wetness that is infertile (your teacher must verify)
  • Sexual relations in the evening
  • Sexual relations in the morning

It is important to begin to distinguish between wet and slippery wet. The following examples may help clarify this distinction:

  • Dry: Putting one's hand in an empty bucket
  • Wet: Putting one's hand in a bucket of water
  • Slippery Wet: Putting one's hand in a bucket of soapy water, or water with oil added to it, or grabbing the fish that is swimming in the bucket of water
  • Dry: Rubbing the lips with the fingers
  • Wet: Rubbing the lips with the tongue
  • Slippery Wet: Put on lip gloss and rub the lips with the tongue

A woman's mucus pattern will be individual and cannot be known beforehand. You will learn your individual mucus pattern by making daily observations and keeping an accurate chart. Sexual intercourse and genital contact are avoided during the first two to four weeks of observation to enable you to recognize the cervical mucus secretion without being confused by the presence of seminal fluid or arousal fluid.

A woman should learn to tell the difference between seminal fluid and arousal fluid and her cervical mucus discharge. Cervical mucus will stretch again and again without breaking. Seminal fluid, when rolled between the fingers, will foam, may even stretch, but immediately breaks and disappears as water would. Arousal fluid, when rolled between the fingers, feels lubricative and slippery, may even be stretchy, but goes away quickly as water would.

Douching is not necessary, could wash away mucus and contributes to the destruction of the natural bacterial balance in the vagina, increasing the potential dangers of infection.

 

Postponing Pregnancy for the Breastfeeding Mother

Total breastfeeding means that the baby is receiving complete nutritional requirements from the mother and is contented and gaining weight. This involves the mother and baby in a close relationship, offering the breast as a pacifier, feeding the baby during the night and letting the baby nurse as often as he wishes. The amount and frequency of sucking is very closely related to the natural infertility of breastfeeding. The use of pacifiers or giving water encourages the baby to suck less at the breast, hence ovulation will likely return earlier than it would if the baby were totally breastfeeding.

Total breastfeeding can delay the return of ovulation a minimum of three months. When ovulation does return, it is often before the first menses. About half of all breastfeeding mothers will return to cycles during the time of weaning. Even while totally breastfeeding, the body may try to ovulate at about three months. If the mother can get extra rest and give extra feedings, she will most likely return to her basic infertile pattern. Again, as the baby gets older, even with total breastfeeding there may be a rise in the body hormones associated with fertility. The mother may again choose to give extra breastfeedings and get extra rest, thus repressing her return to fertility. According to Dr. Evelyn Billings, infertility is a more natural state while breastfeeding because the rise in hormones changes the flavor of the milk and may cause the baby to fuss.

Charting should begin as soon as the bleeding after childbirth has stopped, usually about three weeks after the birth of the baby. Two to three weeks of abstinence with careful observing and charting should allow the woman to recognize her basic infertility. Nursing mothers also need to pay special attention to changes in sensation as well as visual observations. An inexperienced woman would be advised to keep in close contact with an instructor.

Once the woman has learned to recognize her basic infertile pattern, marital relations are open to the couple in the evenings (only) on days of the Basic Infertile Pattern, but not on consecutive evenings. Marital relations must be avoided during any change from the basic infertile pattern and for three days after the return of the basic infertile pattern. (That means that the evening of day four is again open to relations.) Mucus patches, all bleeding and even spotting should be considered a possible fertile sign. That is, the couple must abstain during these changes and for three full days after the pattern of infertility has returned. Careful charting is important throughout nursing, particularly as solids are introduced.

After ovulation has been clearly recognized for three consecutive cycles, and providing the weaning process is complete, the couple may assume that cycles have returned to normal. A clearly recognized ovulation is defined as a clear mucus pattern followed by a normal menstruation eleven to sixteen days later.

Robin Lim is an author, midwife and educator who lives in Bali with her husband and children. Click here for a full bio.

Marie Zenack is a Master Teacher of Ovulation Method of Natural Family Planning.


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