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'''Natural family planning''' (NFP) is a term referring to the [[family planning]] methods approved by the [[Roman Catholic Church]]. In accordance with the requirements for [[human sexual behavior|sexual behavior]] in keeping with the dignity of the human person, as maintained by this church, NFP excludes the use of other methods of [[birth control|contraception]], as well as acts intended to end in orgasm outside the context of vaginal intercourse.
'''Natural family planning''' (NFP) is a term referring to the [[family planning]] methods approved by the [[Roman Catholic Church]]. In accordance with the requirements for [[human sexual behavior|sexual behavior]] in keeping with the dignity of the human person, as maintained by this church, NFP excludes the use of other methods of [[birth control|contraception]], as well as acts intended to end in orgasm outside the context of vaginal intercourse.


Periodic [[sexual abstinence|abstinence]] and the [[lactational amenorrhea method|natural infertility]] caused by [[breastfeeding]] are the only methods deemed moral for avoiding [[pregnancy]]. When used to avoid pregnancy, NFP limits sexual intercourse to naturally infertile periods: during infertile portions of the [[menstrual cycle]], during pregnancy, or after the [[menopause]]. Several methods may be used to identify whether a woman is likely to be [[fertility|fertile]], which NFP users make use of to either try to avoid or to achieve pregnancy.
Periodic [[sexual abstinence|abstinence]] and the [[lactational amenorrhea method|natural infertility]] caused by [[breastfeeding]] are the only methods deemed moral for avoiding [[pregnancy]]. When used to avoid pregnancy, NFP limits sexual intercourse to naturally infertile periods: during infertile portions of the [[menstrual cycle]], during pregnancy, or after the [[menopause]]. Several methods may be used to identify whether a woman is likely to be [[fertility|fertile]], which NFP users make use of to either try to avoid or try to achieve pregnancy.


==Prevalence==
==Prevalence==

Revision as of 22:51, 29 March 2009

This article is about methods of family planning approved by the Roman Catholic Church. For a more general use of the term, see fertility awareness.
Natural family planning
Background
Typebehavioral
First useAncient: calendar, LAM
mid-1930s: BBT
1950s: mucus
Failure rates (First six months: LAM
Per year: symptoms- and calendar-based)
Perfect useLAM: 0.5%
Symptoms based: 1-3%
Calendar based: 5-9%
Typical useLAM: 2%
Symptoms based: 2-25%
Calendar based: 25%
Usage
ReversibilityYes
User remindersDependent upon strict user adherence to method
Clinic reviewNone
Advantages and disadvantages
STI protectionNo
Period advantagesPrediction
BenefitsIn accord with Catholic teachings, no drug effects, can aid pregnancy achievement

Natural family planning (NFP) is a term referring to the family planning methods approved by the Roman Catholic Church. In accordance with the requirements for sexual behavior in keeping with the dignity of the human person, as maintained by this church, NFP excludes the use of other methods of contraception, as well as acts intended to end in orgasm outside the context of vaginal intercourse.

Periodic abstinence and the natural infertility caused by breastfeeding are the only methods deemed moral for avoiding pregnancy. When used to avoid pregnancy, NFP limits sexual intercourse to naturally infertile periods: during infertile portions of the menstrual cycle, during pregnancy, or after the menopause. Several methods may be used to identify whether a woman is likely to be fertile, which NFP users make use of to either try to avoid or try to achieve pregnancy.

Prevalence

It is estimated that 2–3% of the world's reproductive age population relies on periodic abstinence to avoid pregnancy.[1] Breastfeeding is believed to reduce the world's fertility rate by 30–45%.[2] However, what portion of this population should be considered NFP users is unclear. Some Catholic sources consider couples that violate the religious restrictions associated with natural family planning to not be NFP users.[3][4]

There is little data on the worldwide use of natural family planning. In Brazil, NFP is the third most popular family planning method.[5] The "safe period" method of fertility awareness is the most common family planning method used in India, although condoms are used by some.[6]

Use of NFP in developed countries is low, even among Catholics. While Catholics made up 24% of the U.S. population in 2002,[7] of reproductive age American women using birth control, only 1.5% were using periodic abstinence.[8]

Use of NFP is not restricted to Catholic couples. In 2002, Sam and Bethany Torode, then a Protestant Christian couple, published a book advocating NFP use.[9] (Five years after writing the book, the Torodes retracted their advocacy of pure NFP and also supported barrier methods as moral; the couple also converted from Protestantism to the Eastern Orthodox Church.)[10]

Methods

There are three main types of NFP: the symptoms-based methods, the calendar-based methods, and the lactational amenorrhea method. Symptoms-based methods rely on biological signs of fertility, while calendar-based methods estimate the likelihood of fertility based on the length of past menstrual cycles.

Symptoms-based

Cervical mucus

Some methods of NFP track biological signs of fertility. When used outside of the Catholic concept of NFP, these methods are often referred to simply as fertility awareness methods rather than NFP.[11] The three primary signs of a woman's fertility are her basal body temperature, her cervical mucus, and her cervical position.[12] Computerized fertility monitors may track basal body temperatures, hormonal levels in urine, or changes in electrical resistance of a woman's saliva.[13]

From these symptoms, a woman can learn to assess her fertility without use of a computerized device. Some systems use only cervical mucus to determine fertility. Two well-known mucus-only methods are the Billings ovulation method and the Creighton Model FertilityCare System. If two or more signs are tracked, the method is referred to as a symptothermal method. Two popular symptothermal systems are that taught by the Couple to Couple League and the Fertility Awareness Method (FAM) taught by Toni Weschler.[14]

In Canada, the symptothermal method is taught by SERENA Canada which is an inter-denominational organization which has been developing the Symptothermal Method as a part of NFP since 1955. They are also not specifically affiliated with the Roman Catholic Church.

Calendar-based

Calendar-based methods determine fertility based on a record of the length of previous menstrual cycles. They include the Rhythm Method and the Standard Days Method.[15]

Lactational amenorrhea

The lactational amenorrhea method (LAM) is a method of avoiding pregnancy based on the natural postpartum infertility that occurs when a woman is amenorrheic and fully breastfeeding. The rules of the method help a women identify and possibly lengthen her infertile period. A strict version of LAM is known as ecological breastfeeding.[16]

Effectiveness

Calendar-based methods, which are sometimes considered NFP,[17] but also not classified as NFP by the United States Conference of Catholic Bishops,[18] have perfect-use pregnancy rates of 5–9% per year, while symptoms-based and lactational methods of NFP have lower perfect-use pregnancy rates: between 1%–3% per year. The common usage pregnancy rate varies with the method being taught, the teaching technique, and the population being studied. Pregnancy rates of 2%[19] to 25% per year have been reported.[20][21][22][23][24]

Method limitations

  • Some fertility awareness forms of NFP require observation or touching of cervical mucus, an activity with which some women are not comfortable.
  • Some drugs, such as decongestants, can change cervical mucus. Women may not be able to rely on mucus-only forms of NFP while taking these drugs.[25]
  • Some fertility awareness forms require tracking of basal body temperatures. Because irregular sleep can interfere with the accuracy of basal body temperatures, shift workers and those with very young children, for example, might not be able to rely on those methods.[25]
  • The NFP methods that encourage breastfeeding infertility can only be used until the woman's first post-partum menstruation. Even the most strict form results in average return of menses at 14 months post-partum,[26][27] and menstruation can return as early as 6 weeks post-partum.[28]
  • NFP does not protect against sexually transmitted disease.[29]

Theology

Main article: Christian views on contraception § Roman Catholic Church

Official Catholic

Catholic doctrine holds that God created sexual intercourse to be both unitive and procreative.[30] This church considers deliberately altering fertility or the marital act with the intention of preventing procreation to be sinful. Thus, artificial birth control methods are forbidden, as are acts intended to end in orgasm outside the context of intercourse (e.g. masturbation or oral sex that is not part of foreplay).[31] At the same time, not having sex at all (abstinence) is considered morally acceptable.[30]

Having sex at an infertile time in a woman's life (such as pregnancy or post-menopause) is also considered acceptable, since the infertile condition is considered to be created by God, rather than as an act by the couple.[32] Similarly, under Catholic theology, it may be morally acceptable to abstain during the fertile part of the woman's menstrual cycle.[30] Increasing the postpartum infertile period through particular breastfeeding practices — the lactational amenorrhea method — is also considered a natural and morally unobjectionable way to space a family's children.[33]

The Catholic Church acknowledges a potential benefit of spacing children[30] and use of NFP for this reason is encouraged. Humanae Vitae cites "physical, economic, psychological and social conditions" as possibly compelling reasons to avoid pregnancy.[34] Couples are warned, however, against using NFP for selfish, immoral, or insincere reasons.[30] A few Catholic theologians argue that couples with several children may morally choose to avoid pregnancy, even if their circumstances (emotional, physical, and economic) would allow for more children.[35] More commonly, Catholic sources extol the benefits children bring to their parents, their siblings, and society in general, and encourage couples to have as many children as their circumstances make practical.[36][37][38][39]

Dissident and other opposing

See also: Christian views on contraception § Natural Family Planning only or "artificial" methods too?

Some Catholics have voiced significant disagreement with this church's stance on contraception.[40] The Canadian Conference of Catholic Bishops issued a heavily dissenting document, the Winnipeg Statement. In it, the bishops argued that many Catholics found it very difficult, if not sometimes impossible, to obey Humanae Vitae. Additionally, they reasserted the Catholic principle of primacy of conscience.[41] Catholics such as Fr. Charles Curran have also criticized the stance of Vitae on artificial birth control.[42]

Theological opposition has additionally come from Protestant Christianity. John Piper's Desiring God ministry states of NFP, "There is no reason to conclude that natural family planning is appropriate but that 'artificial' means are not."[43] Sam and Bethany Torode, former advocates of NFP-only, have redacted their position to include barrier methods and explain their current theology this way:

We also see honest congruity with the language of the body by saying "no" to conception with our bodies (via barrier methods or sensual massage) when our minds and hearts are also saying "no" to conception. We don’t believe this angers God, nor that it leads to the slippery slope of relativism or divorce. We strongly disagree with the idea that this is a mortal sin.... it’s a theological attack on women to always require that abstinence during the time of the wife’s peak sexual desire (ovulation) for the entire duration of her fertile life, except for the handful of times when she conceives.[10]

Potential advantages

Fertility awareness methods of NFP can be used to track reproductive health in general, and aid in the diagnosis of gynecological health and/or fertility problems. Particularly with the symptothermal method, which is based on a scientific method of self-observation, temperature, external and internal mucus, and cervical observations are all recorded daily on a calendar. Any observation of irregularities may prove helpful, providing a doctor or gynecologist with important diagnostic information with dates and a personal history of any abnormalities.[44] The fertility knowledge gained from NFP methods may also be used to help achieve pregnancy.[45]

NFP has none of the side effects associated with hormonal methods and spermicides.[31] During the infertile period, NFP also allows for intercourse without barrier methods. This is held to allow for more spontaneous sex, as barrier methods are commonly considered to reduce sexual spontaneity.[46]

NFP can be free or very low-cost.[45] Some methods encourage the use of a thermometer and/or photocopied charts, which can be obtained relatively inexpensively. Some couples choose to use software or to use other devices such as a string of beads for counting the days.

Divorce rate

Proponents of NFP say it increases marital satisfaction and helps lower divorce rates. Anecdotal evidence and small studies are put forth in support of this view.[47] One study involving 505 women using NFP found a correlation between lower divorce rates and the use of NFP.[48]

Claims regarding communication

Fertility awareness forms of NFP have resulted in couples communicating more about their bodies and sexuality; supporters say it improves communication skills throughout the entire marriage. One proposed explanation, called a "courtship and honeymoon effect",[49][50] is that the scheduled abstinence encourages couples to express love in non-sexual ways, and to have a greater appreciation for intercourse when it does happen.[51]

Potential disadvantages

Abstinence requirement

  • The fertility awareness and statistical forms of NFP require periodic abstinence, known as sexual continence, typically for 8–10 days of each menstrual cycle. It is common for the woman's sexual desire to be highest on those fertile days, and low in other parts of the cycle.[52] That the couple must abstain from sex during the woman's periods of peak sexual desire may be deeply frustrating for both partners, and lead to feelings of isolation.[10]
  • Some methods of NFP require up to six months of research and observation (and abstinence) in order to collect baseline data, so these methods cannot be immediately implemented by a new user.[53]
  • Couples seeking the lowest risk of pregnancy (less than 1% per year) may be required to abstain for more than half of each menstrual cycle.[54]
  • For women in certain situations — breastfeeding, perimenopause, or with hormonal disorders such as PCOS - abstinence may be required for months at a time.[10]
  • When taught in the context of Catholicism, this church teaches that orgasmic acts outside of intercourse, such as consummated masturbation and oral sex, are morally incompatible with the correct practice of NFP. Some couples are not comfortable with this restriction. Periodic abstinence also limits spontaneous sex.[29]

Implantation failure and miscarriage

  • In 2006, a moral philosopher authored a widely read article in which he speculated that unprotected intercourse in the infertile periods of the menstrual cycle may still result in conceptions, but create embryos incapable of implanting.[55]
  • In the 1980s, some epidemiologic studies suggested that pregnancies resulting from method failures of NFP were at increased risk of miscarriage and birth defects due to aged gametes at the time of conception.[56] The most recent research, however, suggests timing of conception has no effect on miscarriage rates,[57] low birth weight, or preterm delivery.[58]

See also

References

  • "Humane Vitae". Encyclical of Pope Paul VI. The Holy See. July 25 1968. Retrieved 2006-06-15. {{cite web}}: Check date values in: |date= (help)
  • Kippley, Sheila; Kippley, John F. (1996). The art of natural family planning (4th Edition ed.). Cincinnati, OH: Couple to Couple League International. ISBN 0-926412-13-2. {{cite book}}: |edition= has extra text (help)CS1 maint: multiple names: authors list (link)

Notes

  1. ^ Che Y, Cleland J, Ali M (2004). "Periodic abstinence in developing countries: an assessment of failure rates and consequences". Contraception. 69 (1): 15–21. doi:10.1016/j.contraception.2003.08.006. PMID 14720614.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  2. ^ Kippley (1996), p. 145
  3. ^ Kippley (1996), p. 13
  4. ^ "Question #8". FREQUENTLY ASKED QUESTIONS. Serena Canada. 2006. Retrieved 2007-03-19.
  5. ^ Keller S (1996). "Traditional beliefs part of people's lives". Network. 17 (1): 10–1. PMID 12320441.
  6. ^ Urmil Dosajh, Ishita Ghosh, and Rebecka Lundgren (September 2005). "Feasibility of Incorporating the Standard Days Method into CASP Family Planning Services in Urban Slums of India" (PDF). The Institute for Reproductive Health, Georgetown University: p. vi. Retrieved 2008-02-18. {{cite journal}}: |pages= has extra text (help); Cite journal requires |journal= (help)CS1 maint: multiple names: authors list (link)
  7. ^ "Largest Religious Groups in the United States of America". Adherents.com. 2005. Retrieved 2007-03-19.
  8. ^ Chandra, A (2005). "Fertility, Family Planning, and Reproductive Health of U.S. Women: Data From the 2002 National Survey of Family Growth" (PDF). Vital Health Stat. 23 (25). National Center for Health Statistics. Retrieved 2007-05-20. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help) See Table 56.
  9. ^ Sam Torode, Bethany Torode, J. Budziszewski (2002). Open Embrace: A Protestant Couple Rethinks Contraception. Grand Rapids, Michigan: Wm. B. Eerdmans Publishing Company. ISBN 0-8028-3973-8. {{cite book}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  10. ^ a b c d Torode, Bethany (2006). "An Update From Bethany". Retrieved 2007-03-13.
  11. ^ Weschler, Toni (2002). Taking Charge of Your Fertility (Revised Edition ed.). New York: HarperCollins. p. 5. ISBN 0-06-093764-5. {{cite book}}: |edition= has extra text (help)
  12. ^ Weschler, p.52
  13. ^ Basal body temperatures: Ladycomp-babycomp.com
    Hormone levels in urine: Clearblue Easy Fertility Monitor home page
    Changes in electrical resistance of saliva: Ovacue website
  14. ^ Unlike the organizations associated with other popular observational systems, Toni Weschler has no connection to the Roman Catholic Church.
  15. ^ "Medical Eligibility Criteria for Contraceptive Use:Fertility awareness-based methods". Third edition. World Health Organization. 2004. Retrieved 2008-04-29. {{cite journal}}: Cite journal requires |journal= (help)
  16. ^ "Ecological Breastfeeding" (Internet Archive). Couple to Couple League International. Internet Archive. 2006. Retrieved 2008-06-04.
  17. ^ Examples being: "Natural Family Planning". Student Health Service. University of Pennsylvania., "natural family planning". Perimon. and "Fertility Awareness Methods: Natural Family Planning". Baby Art.
  18. ^ "Basic Information on Natural Family Planning". United States Conference of Catholic Bishops. 2007. {{cite web}}: Unknown parameter |month= ignored (help)
  19. ^ Frank-Herrmann P, Freundl G, Gnoth C; et al. (June–September 1997). "Natural family planning with and without barrier method use in the fertile phase: efficacy in relation to sexual behavior: a German prospective long-term study". Advances in Contraception. 13 (2–3): 179–189. doi:10.1023/A:1006551921219. PMID 9288336. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: date format (link) CS1 maint: multiple names: authors list (link)
  20. ^ "Facts in Brief: Contraceptive Use". Guttmacher Institute. 2005. Retrieved 2006-06-19. {{cite web}}: Unknown parameter |month= ignored (help)
  21. ^ Frank-Herrmann P, Freundl G, Baur S; et al. (1991). "Effectiveness and acceptibility of the symptothermal method of natural family planning in Germany". Am. J. Obstet. Gynecol. 165 (6 Pt 2): 2052–4. PMID 1755469. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  22. ^ Clubb EM, Pyper CM, Knight J (1991). "A pilot study on teaching natural family planning (NFP) in general practice". Proceedings of the Conference at Georgetown University, Washington, DC. {{cite conference}}: Unknown parameter |booktitle= ignored (|book-title= suggested) (help)CS1 maint: multiple names: authors list (link)
  23. ^ The European Natural Family Planning Study Groups (1993). "Prospective European multi-center study of natural family planning (1989-1992): interim results". Adv Contracept. 9 (4): 269–83. PMID 8147240.
  24. ^ Frank-Herrmann P, Freundl G, Gnoth C; et al. (1997). "Natural family planning with and without barrier method use in the fertile phase: efficacy in relation to sexual behavior: a German prospective long-term study". Adv Contracept. 13 (2–3): 179–89. PMID 9288336. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  25. ^ a b "How to Observe and Record Your Fertility Signs". Fertility Friend Handbook. Tamtris Web Services. 2004. Retrieved 2005-06-15.
  26. ^ Kippley SK, Kippley JF (1972). "The relation between breastfeeding and amenorrhea: report of a survey". JOGN Nurs. 1 (4): 15–21. PMID 4485271. {{cite journal}}: Unknown parameter |month= ignored (help)
  27. ^ Sheila Kippley (November–December 1986). "Breastfeeding survey results similar to 1971 study". The CCL News. 13 (3): 10.{{cite journal}}: CS1 maint: date format (link) and 13:4 (January-February 1987) 5.
  28. ^ "Postpartum Visit Checklist". StorkNet.com. Retrieved 2006-06-24.
  29. ^ a b "Natural family planning". University of Iowa Health Care Website. McKesson Health Solutions. 2003. Retrieved 2006-06-15.
  30. ^ a b c d e "#2363-2370". Catechism of the Catholic Church, Second Edition. United States Catholic Conference. 2000. pp. Article 6: The Sixth Commandment. Retrieved 2006-06-15.
  31. ^ a b Christopher West (2000). Good News about Sex and Marriage: Answers to Your Honest Questions about Catholic Teaching. Servant Publications. pp. 88–91.
  32. ^ "Casti Connubii". Encyclical of Pope Pius XI. United States Catholic Conference. 1930. pp. Section 59. Retrieved 2006-06-15.
  33. ^ "NFP - Two basic forms". Couple to Couple League. Retrieved 2006-06-24.
  34. ^ Humane Vitae (1968) Section I.10
  35. ^ Thomas Storck (2006). "NFP: A Defense and an Explanation". Retrieved 2007-04-27. {{cite journal}}: Cite journal requires |journal= (help), which cites:
    Ford, John C. (1963). Contemporary Moral Theology: Vol.2 (II), Marriage Questions. Westminster, Md: Newman Press. pp. 422–423. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  36. ^ Humanae Vitae (1968) Section I.9
  37. ^ "The Blessings of Children". One More Soul. Retrieved 2006-06-24.
  38. ^ "In Praise of Big Families". CatholicExchange.com. Retrieved 2006-06-24.
  39. ^ "Principles of the Couple to Couple League". Couple to Couple League International. Retrieved 2006-06-24.
  40. ^ Roderick Hindery (1990). "The Evolution of Freedom as Catholicity in Catholic Ethics". In Ed. Starr, Bradley E.; Gard, Donald; Benjamin J. Hubbard (ed.). Anxiety, guilt, and freedom: religious studies perspectives: essays in honor of Donald Gard. Washington, D.C: University Press of America. ISBN 0-8191-7683-4.{{cite book}}: CS1 maint: multiple names: editors list (link) - A summary and restatement of the debate
  41. ^ "Canadian Bishops' Statement on the Encyclical "Humanae Vitae"". Retrieved 2006-10-02.
  42. ^ Curran, Charles E. (2006). Loyal Dissent: Memoir of a Catholic Theologian (Moral Traditions). Washington, D.C: Georgetown University Press. ISBN 1-58901-087-6.
  43. ^ Desiring God Staff (2006). "Does the Bible permit birth control?" (html). Questions and Answers. Desiring God. Retrieved 2006-10-27.
  44. ^ Cimperman, Sarah (2005). "Fertility Awareness for Reproductive Health". Santé! Holistic Health News from Dr. Sarah Cimperman Newsletter. Retrieved 2006-06-15. {{cite web}}: Unknown parameter |month= ignored (help)
  45. ^ a b "Basic Information on Natural Family Planning". Natural Family Planning. United States Conference of Catholic Bishops. Retrieved 2006-06-15.
  46. ^ "Advantages of NFP". Natural beauty. Couple to Couple League. 2005. Retrieved 2008-02-01.
  47. ^ "Marital Duration and Natural Family Planning". The Couple to Couple League. 2005. Retrieved 2008-03-30.
  48. ^ Wilson, Mercedes Arzú (2002). "The Practice Of Natural Family Planning Versus The Use Of Artificial Birth Control: Family, Sexual And Moral Issues" (PDF). Catholic Social Science Review. VII. Retrieved 2008-03-30. {{cite journal}}: Unknown parameter |month= ignored (help)
  49. ^ Kippley (1996), p. 246
  50. ^ Weschler, Toni (2002). Taking Charge of Your Fertility (Revised Edition ed.). New York: HarperCollins. p. 123. ISBN 0-06-093764-5. {{cite book}}: |edition= has extra text (help)
  51. ^ Shivanandan, Mary (1999). "NFP & the Couple's Relationship". Diocesan Development Program for Natural Family Planning. Retrieved 2006-06-15. {{cite web}}: Text "work Diocesan Development Program for Natural Family Planning" ignored (help)
  52. ^ Bullivant SB, Sellergren SA, Stern K; et al. (2004). "Women's sexual experience during the menstrual cycle: identification of the sexual phase by noninvasive measurement of luteinizing hormone". J Sex Res. 41 (1): 82–93. PMID 15216427. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link) - in online article, see pp.14-15,18-22
  53. ^ "Safer Sex and Contraception - Natural Family Planning". Family Planning Victoria. 2005. Retrieved 2006-07-06.
  54. ^ Frank-Herrmann P, Heil J, Gnoth C; et al. (2007). "The effectiveness of a fertility awareness based method to avoid pregnancy in relation to a couple's sexual behaviour during the fertile time: a prospective longitudinal study". Hum. Reprod. 22 (5): 1310–9. doi:10.1093/humrep/dem003. PMID 17314078. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  55. ^ Luc Bovens (2006). "The rhythm method and embryonic death" (PDF). Journal of Medical Ethics. 32: 355–356. {{cite journal}}: External link in |journal= (help)
  56. ^ Gray RH (1984). "Aged gametes, adverse pregnancy outcomes and natural family planning. An epidemiologic review". Contraception. 30 (4): 297–309. PMID 6509983. {{cite journal}}: Unknown parameter |month= ignored (help)
  57. ^ Gray RH, Simpson JL, Kambic RT; et al. (1995). "Timing of conception and the risk of spontaneous abortion among pregnancies occurring during the use of natural family planning". Am. J. Obstet. Gynecol. 172 (5): 1567–72. PMID 7755073. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  58. ^ Barbato M, Bitto A, Gray RH; et al. (1997). "Effects of timing of conception on birth weight and preterm delivery of natural family planning users". Adv Contracept. 13 (2–3): 215–28. PMID 9288339. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

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