Estudio sobre el metodo billing
4
8/19/2019 Estudio sobre el metodo billing http://slidepdf.com/reader/full/estudio-sobre-el-metodo-billing 1/4 EDUCATION & DEBATE Natural family planning : effective birth control supported by the Catholic Church RE J Ryder During 20-22 September Manchester is to host the 1993 follow up to last year s earth summit in Rio de Janeiro. At that summit the threat posed by world overpopulation received considerable attention. Catholicism was perceived as opposed to birth control and therefore as a particular threat. This was based on the notion that the only method of birth control approved by the church-natural family planning-is unreliable, unacceptable, and ineffec- tive. In the 20 years since E L Billings and colleagues first described the cervical mucus symptoms associated with ovulation natural family planning has incorporated these symptoms and advanced considerably Ultrasonography shows that the symptoms identify ovulation precisely. According to the World Health Organisation, 93% of women everywhere can identify the symptoms, which dis- tinguish adequately between the fertile and infertile phases of the menstrual cycle. Most pregnancies during trials of natural family planning occur after intercourse at times recognised by couples as fertile. Thus pregnancy rates have depended on the motiva- tion of couples. Increasingly studies show that rates equivalent to those with other contraceptive methods are readily achieved in the developed and developing worlds. Indeed, a study of 19843 poor women in India had a pregnancy rate approaching zero. Natural family planning is cheap, effective, without side effects, and m ay be particularly accept- able to and efficacious among people in areas of poverty. Department of Endocrinology, Dudley Road Hospital, Birmingham B18 7QH R E J Ryder, consultant physician BM 7 1993;307:723-6 The 1993 follow up to last year s earth summit in Rio de Janeiro is to take place in Manchester during 20-22 September and is entitled Partnerships for change. The Rio earth summit focused considerable attention on the expanding population of the world as an important issue in relation to resources, environment, and poverty. In the media the opposition of the Catholic Church to birth control was discussed (BBC Radio 4, TodayProgramme, 18 M ay 1992) and considered to be an important factor with the many millions of Catholics in the world, particularly the Third World, such as Brazil. In the medical press the Pope's continuing opposition to birth control was condemned' and powerful Vatican opposition was considered likely to wreck hope of useful progress at the earth summit with regard to global overpopulation as a most urgent ecological hazard.2 The widespread beliefs that the Catholic Church is opposed to birth control, that the urgent provision of artificial contraception within the Third World is the only answer to overpopulation, and that the Catholic Church is opposed to this2 all stem from the percep- tion that the so called natural methods of family planning, which are approved by the Catholic Church, are unreliable, unacceptable, and ineffective. Historic- ally, this perception is based on the unreliability of the rhythm method of contraception ( Roman roulette ), which attempts to identify the fertile phase of the woman's cycle by calendar calculations. Is this perception as accurate today as it m ay have been in the past? The ovum has a life span of not more than 24 hours and is fertilisable for only part of that time.3 The life span of the sperm m ay be measured in hours under adverse conditions. Under optimum conditions, how- ever, sperms m ay remain viable for four or five days, and a life span of up to sevendayshas been postulated.3 Thus a woman is potentially fertile for no more than six to eight days of her cycle, probably less in most cases. To what extent can these potentially fertile days be accurately identified and avoided by most women as a method of birth control? Cyclical changes incervical mucus secretion In 1972 Billings et al reported the characteristic changes in cervical mucus secretion which occur during the menstrual cycle.4 After menstruation there are a variable number of dry days with little or no mucus secretion and a feeling of dryness in thevaginal area. Then, as ovulation approaches under the influ- ence of increasing oestrogen conicentrations35 the dry feeling ends and there is increasing secretion of cervical mucus, which at the time of ovulation becomes an abundant discharge of substance like the raw white of an egg. After ovulation the first secretion of proges- terone abruptly reverses the effect of oestrogen on cervical mucus and causes it to become thick and rubbery, forming a plug in the cervix. The fertile- type, raw egg white cervical mucus is of low viscosity and high threadability (spinnbarkeit) with glyco- protein fibrils in a micelle-like structure which aids sperm migration. It contains sugars and trace elements necessary for sperm survival, capacitation, and transport and it can maintain the sperm capable of fertilisation for several days. 56 By contrast, the thick, white, non-stretchy mucus which occurs at other times in the cycle is impenetrable by sperm and hostile to its survival. Other symptoms have been described in association with ovulation, in particular periovulatory pain and the progesterone induced postovulatory rise in basal body temperature. Hormonal studies have confirmed the close relation of the various symptoms with ovulation,47 and more recently ovarian ultrasono- graphy has suggested that the day of most abundant secretion of fertile-type egg white mucus identifies the day of ovulation as precisely as does the luteinising hormone peak (see figure).8 Other symptoms asso- ciated with the cyclical changes in oestrogen and progesterone concentrations include changes in the cervix, breast tissue, skin, hair, libido, and moods. 5 BM J voLuME& 307 18 SEPTMABER 1993 723
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Transcript of Estudio sobre el metodo billing
8/19/2019 Estudio sobre el metodo billing
http://slidepdf.com/reader/full/estudio-sobre-el-metodo-billing 1/4
EDUCATION
&
DEBATE
N a t u r a l
family planning :
e f f e c t i v e b i r t h c o n t r o l
s u p p o r t e d
b y the
C a t h o l i c
C h u r c h
RE
J R y d e r
D u r i n g
2 0 - 2 2 S e p t e m b e r
M a n c h e s t e r
i s
t o h o s t t h e
1 9 9 3
f o l l o w u p t o l a s t y e a r s
e a r t h s u m m i t
i n R i o d e
J a n e i r o . A t t h a t s u m m i t t h e t h r e a t
p o s e d
b y w o r l d
o v e r p o p u l a t i o n
r e c e i v e d c o n s i d e r a b l e a t t e n t i o n .
C a t h o l i c i s m w a s p e r c e i v e d
a s o p p o s e d t o
b i r t h
c o n t r o l a n d
t h e r e f o r e
a s a p a r t i c u l a r
t h r e a t . T h i s w a s
b a s e d o n
t h e
n o t i o n t h a t
t h e
o n l y
m e t h o d o f
b i r t h
c o n t r o l
a p p r o v e d
b y t h e c h u r c h - n a t u r a l
f a m i l y
p l a n n i n g - i s
u n r e l i a b l e , u n a c c e p t a b l e , a n d i n e f f e c -
t i v e .
I n
t h e
2 0 y e a r s
s i n c e
E L B i l l i n g s a n d
c o l l e a g u e s
f i r s t
d e s c r i b e d t h e
c e r v i c a l
mucus
s y m p t o m s
a s s o c i a t e d
w i t h o v u l a t i o n
n a t u r a l
f a m i l y
p l a n n i n g
h a s
i n c o r p o r a t e d t h e s e
s y m p t o m s a n d
a d v a n c e d
c o n s i d e r a b l y U l t r a s o n o g r a p h y s h o w s t h a t t h e
s y m p t o m s i d e n t i f y
o v u l a t i o n
p r e c i s e l y .
A c c o r d i n g t o
t h e W o r l d H e a l t h
O r g a n i s a t i o n ,
9 3 %
o f
women
e v e r y w h e r e
c a n
i d e n t i f y
t h e
s y m p t o m s , w h i c h d i s -
t i n g u i s h
a d e q u a t e l y
b e t w e e n t h e
f e r t i l e a n d
i n f e r t i l e
p h a s e s
o f
t h e
m e n s t r u a l
c y c l e .
M o s t
p r e g n a n c i e s
d u r i n g
t r i a l s o f
n a t u r a l
f a m i l y p l a n n i n g
o c c u r
a f t e r
i n t e r c o u r s e a t t i m e s r e c o gn i s e d b y
c o u p l e s a s
f e r t i l e .
T h u s
p r e g n a n c y
r a t e s h a v e
d e p e n d e d o n t h e
m o t i v a -
t i o n o f
c o u p l e s . I n c r e a s i n g l y
s t u d i e s s h o w
t h a t
r a t e s
e q u i v a l e n t
t o
t h o s e w i t h
o t h e r
c o n t r a c e p t i v e
m e t h o d s a r e
r e a d i l y
a c h i e v e d
i n
t h e
d e v e l o p e d
a n d
d e v e l o p i n g
w o r l d s .
I n d e e d ,
a
s t u d y
o f
1 9 8 4 3
p o o r
women i n I n d i a
h a d
a
p r e g n a n c y
r a t e
a p p r o a c h i n g
z e r o .
N a t u r a l
f a m i l y
p l a n n i n g
i s
c h e a p , e f f e c t i v e ,
w i t h o u t
s i d e
e f f e c t s ,
a n d
may
b e
p a r t i c u l a r l y
a c c e p t -
a b l e t o a n d e f f i c a c i o u s
among p e o p l e
i n
a r e a s o f
p o v e r t y .
D e p a r t m e n t
o f
E n d o c r i n o l o g y ,
D u d l e y
Road
H o s p i t a l ,
B i r m i n g h a m
B 1 8
7QH
R
E
J
R y d e r ,
c o n s u l t a n t
p h y s i c i a n
BM7
1 9 9 3 ; 3 0 7 : 7 2 3 - 6
T h e
1 9 9 3 f o l l o w
u p
t o l a s t
y e a r s
e a r t h s u m m i t
i n
R i o
d e
J a n e i r o
i s t o t a k e
p l a c e
i n
M a n c h e s t e r
d u r i n g
2 0 - 2 2
S e p t e m b e r
a n d i s e n t i t l e d
P a r t n e r s h i p s
f o r
c h a n g e .
T h e R i o
e a r t h
s u m m i t f o c u s e d c o n s i d e r a b l e a t t e n t i o n
o n
t h e
e x p a n d i n g p o p u l a t i o n
o f t h e
w o r l d
a s a n
i m p o r t a n t i s s u e
i n
r e l a t i o n t o
r e s o u r c e s , e n v i r o n m e n t ,
a n d
p o v e r t y .
I n t h e
m e d i a
t h e o p p o s i t i o n
o f
t h e
C a t h o l i c
C h u r c h
t o b i r t h c o n t r o l
w a s
d i s c u s s e d
( B B C
R a d i o
4 ,
T o d a y P r o gr a mm e ,
1 8
May 1 9 9 2 )
a n d
c o n s i d e r e d
t o b e
a n
i m p o r t a n t
f a c t o r
w i t h
t h e
many
m i l l i o n s o f C a t h o l i c s
i n
t h e
w o r l d , p a r t i c u l a r l y
t h e
T h i r d
W o r l d ,
s u c h
a s
B r a z i l . I n
t h e
m e d i c a l
p r e s s
t h e
P o p e ' s c o n t i n u i n g o p p o s i t i o n t o
b i r t h
c o n t r o l w a s
c o n d e m n e d '
a n d
p o w e r f u l
V a t i c a n
o p p o s i t i o n
w a s
c o n s i d e r e d
l i k e l y
t o
w r e c k
h o p e
o f u s e f u l
p r o g r e s s
a t
t h e e a r t h s u m m i t w i t h
r e g a r d
t o
g l o b a l o v e r p o p u l a t i o n
a s a
m o s t
u r g e n t
e c o l o g i c a l
h a z a r d . 2
T h e
w i d e s p r e a d
b e l i e f s t h a t t h e C a t h o l i c C h u r c h i s
o p p o s e d
t o
b i r t h
c o n t r o l ,
t h a t t h e
u r g e n t p r o v i s i o n
o f
a r t i f i c i a l
c o n t r a c e p t i o n
w i t h i n t h e
T h i r d
W o r l d
i s
t h e
o n l y
a n s w e r
t o
o v e r p o p u l a t i o n ,
a n d t h a t t h e C a t h o l i c
C h u r c h
i s
o p p o s e d
t o
t h i s 2 a l l
s t e m f r o m
t h e
p e r c e p -
t i o n t h a t t h e s o c a l l e d
n a t u r a l
m e t h o d s o f
f a m i l y
p l a n n i n g ,
w h i c h
a r e
a p p r o v e d b y
t h e
C a t h o l i c
C h u r c h ,
a r e u n r e l i a b l e , u n a c c e p t a b l e , a n d
i n e f f e c t i v e .
H i s t o r i c -
a l l y ,
t h i s
p e r c e p t i o n
i s b a s e d
o n
t h e
u n r e l i a b i l i t y o f t h e
r h y t h m m e t h o d o f
c o n t r a c e p t i o n
( R o m a n r o u l e t t e ) ,
w h i c h
a t t e m p t s
t o
i d e n t i f y t h e f e r t i l e
p h a s e o f
t h e
w o m a n ' s c y c l e
b y c a l e n d a r c a l c u l a t i o n s . I s t h i s
p e r c e p t i o n
a s
a c c u r a t e
t o d a y
a s i t may h a v e b e e n
i n
t h e p a s t ?
T h e ovum h a s a l i f e
s p a n o f
n o t m o r e t h a n
2 4
h o u r s
a n d
i s
f e r t i l i s a b l e
f o r o n l y p a r t
o f
t h a t
t i m e . 3 T h e l i f e
s p a n
o f
t h e
s p e r m
may b e
m e a s u r e d
i n
h o u r s
u n d e r
a d v e r s e
c o n d i t i o n s . U n d e r o p t i m u m c o n d i t i o n s ,
h o w -
e v e r , s p e r m s
may r e m a i n v i a b l e
f o r
f o u r
o r f i v e d a y s ,
a n d a l i f e s p a n o f
u p
t o
s e v e n d a y s h a s b e e n p o s t u l a t e d . 3
T h u s
a
woman
i s p o t e n t i a l l y
f e r t i l e
f o r
n o m o r e
t h a n s i x
t o
e i g h t d a y s
o f h e r
c y c l e , p r o b a b l y l e s s
i n
m o s t c a s e s .
To
w h a t e x t e n t
c a n t h e s e p o t e n t i a l l y f e r t i l e d a y s b e
a c c u r a t e l y i d e n t i f i e d
a n d a v o i d e d
b y
m o s t women a s a
m e t h o d o f b i r t h c o n t r o l ?
C y c l i c a l c h a n g e s
i n c e r v i c a l mucus s e c r e t i o n
I n 1 9 7 2
B i l l i n g s
e t a l
r e p o r t e d
t h e c h a r a c t e r i s t i c
c h a n g e s
i n
c e r v i c a l
mucus s e c r e t i o n
w h i c h o c c u r
d u r i n g
t h e
m e n s t r u a l
c y c l e . 4
A f t e r
m e n s t r u a t i o n t h e r e
a r e
a
v a r i a b l e
n u m b e r
o f
d r y
d a y s
w i t h l i t t l e o r n o
m u c u s s e c r e t i o n a n d a f e e l i n g
o f
d r y n e s s
i n t h e v a g i n a l
a r e a .
T h e n ,
a s
o v u l a t i o n
a p p r o a c h e s
u n d e r
t h e
i n f l u -
e n c e
o f
i n c r e a s i n g
o e s t r o g e n
c o n i c e n t r a t i o n s 3 5 t h e
d r y
f e e l i n g
e n d s
a n d t h e r e i s
i n c r e a s i n g
s e c r e t i o n o f c e r v i c a l
m u c u s ,
w h i c h a t t h e t i m e o f o v u l a t i o n b e c o m e s a n
a b u n d a n t
d i s c h a r g e
o f s u b s t a n c e l i k e t h e
r a w
w h i t e
o f
a n
e g g .
A f t e r o v u l a t i o n
t h e f i r s t
s e c r e t i o n o f
p r o g e s -
t e r o n e
a b r u p t l y
r e v e r s e s t h e
e f f e c t o f
o e s t r o g e n
o n
c e r v i c a l
mucus
a n d
c a u s e s
i t
t o
b e c o m e t h i c k
a n d
r u b b e r y , f o r m i n g
a
p l u g
i n t h e c e r v i x . T h e f e r t i l e -
t y p e ,
r a w
e g g
w h i t e
c e r v i c a l
mucus
i s o f l o w
v i s c o s i t y
a n d
h i g h t h r e a d a b i l i t y ( s p i n n b a r k e i t )
w i t h
g l y c o -
p r o t e i n
f i b r i l s
i n a
m i c e l l e - l i k e
s t r u c t u r e
w h i c h
a i d s
s p e r m m i g r a t i o n .
I t
c o n t a i n s
s u g a r s
a n d
t r a c e e l e m e n t s
n e c e s s a r y
f o r
s p e r m s u r v i v a l , c a p a c i t a t i o n ,
a n d
t r a n s p o r t
a n d
i t c a n m a i n t a i n t h e
s p e r m c a p a b l e
o f
f e r t i l i s a t i o n f o r s e v e r a l
d a y s . 5 6 B y
c o n t r a s t ,
t h e
t h i c k ,
w h i t e , n o n - s t r e t c h y
mucus w h i c h o c c u r s a t o t h e r
t i m e s
i n t h e
c y c l e
i s
i m p e n e t r a b l e
b y
s p e r m
a n d
h o s t i l e t o
i t s
s u r v i v a l .
O t h e r
s y m p t o m s
h a v e
b e e n
d e s c r i b e d
i n
a s s o c i a t i o n
w i t h
o v u l a t i o n ,
i n
p a r t i c u l a r p e r i o v u l a t o r y p a i n
a n d
t h e
p r o g e s t e r o n e
i n d u c e d
p o s t o v u l a t o r y
r i s e
i n
b a s a l
b o d y
t e m p e r a t u r e .
H o r m o n a l
s t u d i e s h a v e c o n f i r me d
t h e c l o s e r e l a t i o n o f t h e v a r i o u s
s y m p t o m s
w i t h
o v u l a t i o n , 4 7
a n d
m o r e
r e c e n t l y
o v a r i a n u l t r a s o n o -
g r a p h y
h a s s u g g e s t e d t h a t t h e d a y
o f m o s t
a b u n d a n t
s e c r e t i o n
o f
f e r t i l e - t y p e e g g
w h i t e
mucus
i d e n t i f i e s t h e
d a y
o f
o v u l a t i o n
a s
p r e c i s e l y
a s
d o e s
t h e l u t e i n i s i n g
h o r m o n e
p e a k ( s e e f i g u r e ) . 8
O t h e r
s y m p t o m s
a s s o -
c i a t e d
w i t h t h e
c y c l i c a l
c h a n g e s
i n
o e s t r o g e n
a n d
p r o g e s t e r o n e
c o n c e n t r a t i o n s
i n c l u d e
c h a n g e s
i n t h e
c e r v i x ,
b r e a s t
t i s s u e ,
s k i n , h a i r ,
l i b i d o ,
a n d m o o d s . 5
BM J
v o L u M E &
3 0 7
1 8 S E P T M A B E R 1 9 9 3 7 2 3
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P r e g n a n c y
a n d
c o n t r a c e p t i o n
R e p o r t e d p r e g n a n c y
r a t e s ( p r e g n a n c i e s
p e r 1 0 0
woman y e a r s ;
P e a r l
i n d e x )
i n
w e l l
m o t i v a t e d c o u p l e s
u s i n g t h e c o n d o m ,
d i a p h r a g m , i n t r a u t e r i n e
d e v i c e ,
a n d
p r o g e s t o g e n o n l y
a n d
c o m b i n e d
o e s t r o g e n -
p r o g e s t o g e n o r a l c o n t r a c e p t i o n
a r e 3 T 6 , 1 9 ,
1 - 4 , 1 2 ,
a n d 0 - 1 8
r e s p e c t i v e l y . 9
M u ch h i g h e r
r a t e s h a v e
b e e n
r e c o r d e d , p a r t i c u l a r l y
a m o n g l e s s
m o t i v a t e d c o u p l e s -
f o r e x a m p l e , p r e g n a n c y
r a t e s o f 2 1 a n d 2 2 i n
c o n d o m
u s e r s a n d 2 3
i n d i a p h r a g m
u s e r s . 0 P r e g n a n c y r a t e s o f
2 3
a n d 2 8
h a v e
a l s o
b e e n
r e p o r t e d
i n
u s e r s
o f o r a l
c o n t r a c e p t i v e s
i n
t h e
d e v e l o p i n g
w o r l d .
A s s h o w n
i n
O x f o r d , e v e n
t h e c o n t r a c e p t i v e p i l l
may
f a i l
i f
t h e
woman f o r g e t s
t o
t a k e
i t ,
r un s o u t
o f
t a b l e t s , o r h a s
d i a r r h o e a a n d v o m i t i n g
o r o t h e r i l l n e s s . 2
E a r l y
t r i a l s
o f
b i r t h
c o n t r o l
b a s e d
o n
s y m p t o m
o b s e r v a t i o n 3 - 1 7
y i e l d e d
p r e g n a n c y
r a t e s o f
6
0 7
t o
2 5 * 4 . 1 3 M o s t c o n c e p t i o n s
o c c u r r e d
b e c a u s e o f
i n t e r -
c o u r s e o n d a y s
d e s i g n a t e d
b y
t h e f a m i l y
p l a n n i n g
m e t h o d
a s f e r t i l e . C o n t r o v e r s y
t h e r e f o r e e n s u e d 2
b e t w e e n t h o s e who t h o u g h t t h a t
a l l
p r e g n a n c i e s
o c c u r r i n g
i n
t r i a l s s h o u l d
b e c o n s i d e r e d a s
f a i l u r e s o f
t h e p a r t i c u l a r
m e t h o d 9 2
a n d
t h o s e
who
t h o u g h t
t h a t
t h e m e t h o d
c o u l d n o t
b e
b l a m e d
i f c o u p l e s
h a d
i n t e r c o u r s e
d u r i n g a p h a s e w h i c h
t h e y k n e w t o b e
f e r t i l e . 8 2 0
I t
w a s
a l s o p o s s i b l e t h a t
i n i t i a l s c e p t i c i s m
a b o u t
n a t u r a l
f a m i l y
p l a n n i n g
m e t h o d s
l e d
t o a
c a s u a l
a p p r o a c h b y c o u p l e s .
3
WHO
s t u d y
G i v e n
a
n a t u r a l p r e g n a n c y
r a t e - t h a t
i s ,
t h e
P e a r l
i n d e x w i t h o u t a n y
b i r t h c o n t r o l - e s t i m a t e d
a s
8 0 , 2 2 t h e
c h e a p n e s s
o f n a t u r a l f a m i l y
p l a n n i n g ,
a n d
t h e a c c e p t -
a b i l i t y o f
n a t u r a l
f a m i l y
p l a n n i n g
t o many c u l t u r e s a n d
r e l i g i o n s , t h e
W o r l d H e a l t h
O r g a n i s a t i o n
u n d e r t o o k
a n
i n t e r n a t i o n a l s t u d y . 2 2 7
A
t o t a l o f
8 6 9
women
o f
p r o v e d f e r t i l i t y
a n d
w i d e l y
v a r y i n g c u l t u r a l , e d u c a -
t i o n a l ,
a n d
e c o n o m i c
b a c k g r o u n d s
w e r e s t u d i e d i n f i v e
c e n t r e s ( A u c k l a n d ,
B a n g a l o r e , D u b l i n ,
M a n i l a , a n d
S a n
M i g u e l ,
E l
S a l v a d o r ) .
R e g a r d l e s s
o f
c u l t u r e
a n d
e d u c a t i o n ,
93
o f
t h e
women
r e c o r d e d
a n
i n t e r p r e t -
a b l e o v u l a t o r y
m u c u s p a t t e r n . O f
t h e
E l
S a l v a d o r
w o m e n , 4 8 - 1 % w e r e i l l i t e r a t e a n d y e t r e c o g n i s e d t h e
m u c u s
s y m p t o m s . 2 3
D e t a i l e d a n a l y s i s
i n t h e WHO s t u d y
c o n f i r m e d t h e
p o t e n t i a l
e f f e c t i v e n e s s
o f
m u c u s s y m p t o m
o b s e r v a t i o n
a s
a m e a n s
o f
f a m i l y
p l a n n i n g .
T h e
p r o b a b i l i t y
o f
c o n c e p t i o n
f r o m i n t e r c o u r s e
o u t s i d e t h e
p e r i o d
o f
f e r t i l i t y
d e f i n e d b y
c e r v i c a l m u c u s
o b s e r v a t i o n w a s
0
0 0 4
( s e e t a b l e ) . 2 5
I n t e r c o u r s e o n
d a y s d e s i g n a t e d
a s
f e r t i l e b y
c e r v i c a l m u c u s
o b s e r v a t i o n r e s u l t e d
i n
c o n c e p t i o n
w i t h
i n c r e a s i n g f r e q u e n c y
t h e n e a r e r
t o
o v u l a t i o n
t h a t i n t e r c o u r s e o c c u r r e d ,
i n t e r c o u r s e
o n t h e
p e a k
d a y
o f
c e r v i c a l
mucus
s e c r e t i o n r e s u l t i n g
i n
a
p r o b a b i l i t y
o f
c o n c e p t i o n
o f 0 - 6 6 7
( t a b l e ) . 2 5
T h u s
i t i s
c l e a r
t h a t
women
o f
a l l
c u l t u r e s
a n d
e d u c a t i o n a l
b a c k g r o u n d s
c a n l e a r n t o r e c o g n i s e
when
t h e y
o v u l a t e
i_
os
Lb
c a n
A .
E a r l y
o u s c c u a r
pnase
N o r m a l
ovary e a r l y
i n
m e n s t r u a l
c y c l e .
S c a n
s h o w s
m u l t i p l e
f o l l i c l e s
e a c h o f
8 - 1 0
d i a m e t e r .
No
s i n g l e
f o l l i c l e d o m i n a n t
S c a n
uay 1 2
V i e w o f
r i g h t
o v a r y .
D o m i n a n t
f o l l i c l e
1 4
mm
d i a m e t e r
v i s i b l e
on
r i g h t ,
b e t w e e n t h e two
crosses
S y m p t o m s - F e e l i n g
o f
w e t n e s s ;
no mucus
v i s i b l e
T e m p e r a t u r e
3 6
2 ' C
L u t e i n i s i n g
h o r m o n e 1 2 - 4
U / 1
s c a n
s i a y
i
v
b c a n
L o . i . a y
U
V i e w s
o f s am e f o l l i c l e a s i n
scan
B . F o l l i c l e now F o l l i c l e
2 1 maximum d i a m e t e r
( l e f t
v i e w )
2 0
mm
maximum d i a m e t e r
l e f t
v i e w ) S y m p t o m s - G r e a t e r
amount o f
c l e a r , s l i p p e r y
S y m p t o m s - M o d e r a t e
amount
o f
c l e a r , s l i p p e r y
m u c u s .
P a i n
mucus
T e m p e r a t u r e
3 6
4 ' C
T e m p e r a t u r e
3 6
5 ° C
L u t e i n i s i n g
h o r m o n e 2 3 - 8 U / l
L u t e i n i s i n g
h o r m o n e
1 1 - 8
U / 1
S c a n
E .
D a y
1 7 S c a n F .
D a y
1 8
F o l l i c l e
2 2
maximum
d i a m e t e r .
O v u l a t i o n
F o l l i c l e
has
c o l l a p s e d , l e a d i n g
t o
corpus
l u t e u m
w o u l d
b e
e x p e c t e d
s h o r t l y
( t w o
v i e w s ) .
Maximum d i a m e t e r now 1 5
m m '
S y m p t o m s - A b u n d a n t c l e a r , s l i p p e r y
m u c u s .
S y m p t o m s - C l e a r ,
s l i p p e r y
mucus
l e s s
t h a n on
P a i n
d a y
1 7 .
P a i n
T e m p e r a t u r e
3 6
5 ° C T e m p e r a t u r e
3 6
4 ° C
L u t e i n i s i n g h o r m o n e
5 1 - 5
U A 1
L u t e i n i s i n g
h o r m o n e
not
s a m p l e d
Scan
Day
19
C o r p u s
l u t e u m
( r i g h t
v i e w )
1 1
d i a m e t e r
S y m p t o m s - R e d u c e d
amount o f
m o i s t , s t i c k y ,
c l o u d y
m u c u s .
B a s a l
b o d y t e m p e r a t u r e
r i s e
0
3 ' C
T e m p e r a t u r e
3 6
7 ° C
L u t e i n i s i n g
h o r m o n e
1 5
1
U / 1
BM J
VOLUME
3 0 7
1 8
SEPTEMBER 1 9 9 3
U l t r a s o u n d
s c a n s a n d
c o m m e n t a r y
d e s c r i b i n g
d e v e l o p m e n t
a n d
r u p t u r e o f
o v a r i a n f o l l i c l e . ( F r o m p o s t e r
c o m p i e d f o r
M e d i c a l
R e s e a r c h
S o c i e t y m e e t i n g , N e w c a s d e ,
A u g u s t
1 9 8 5 )
Vi-
7 2 4
8/19/2019 Estudio sobre el metodo billing
http://slidepdf.com/reader/full/estudio-sobre-el-metodo-billing 3/4
P r o b a b i l i t y o f p r e gn a n c y b y p h a s e o f c y c l e a n d d a y s f r o m l a s t d a y
o f f e r t i l e - t y p e
c e r v i c a l m u c u s ( p e a k
d a y )
C y c l e s w i t h No
o f
P r o b a b i l i t y
o f
P h a s e o f
c y c l e R e l a t i o n
t o
p e ak d a y
i n t e r c o u r s e p r e g n a n c i e s p r e g n a n c y
S t i c k y
m u c u s
P e a k
d a y
- 4 o r
e a r l i e r
8 1
2
0 - 0 2 4
S t i c k y m u c u s
P e a k d a y - 3 t o p e a k d a y - 1 6 3
0 5 0 0
S l i p p e r y
m u c u s
P e a k d a y
- 4 o r e a r l i e r 1 7 6
0 - 3 5 3
S l i p p e r y
m u c u s
P e a k d a y
- 3
t o p e a k d a y - 1 2 2 1 2 0 - 5 4 6
P e a k d a y P e a k d a y
0 9 6
0 - 6 6 7
P o s t p e a k P e a k d a y - 1
1 8
8
0444
P o s t p e a k
P e a k d a y
-
2
4 4
9
0 - 2 0 5
P o s t p e a k
P e a k d a y - 3 1 1 2 1 0
0 - 0 8 9
O u t s i d e f e r t i l e p e r i o d
6 1 5 8 2 2 0 0 0 4
A l l
p h a s e s
6 4 6 7
7 8 0 - 0 1 2
D a t a f r o m WHO i n t e m a t i o n a l
s t u d y
o f n a t u r a l
f a m i l y p l a n n i n g
a n d
w h e n
t h e y
a r e
p o t e n t i a l l y f e r t i l e a n d
t h a t i f
i n t e r c o u r s e i s
a v o i d e d
o n p o t e n t i a l l y
f e r t i l e
d a y s
p r e g n a n c i e s
w i l l n o t
o c c u r .
I n c r e a s e d c o n f i d e n c e i n n a t u r a l c o n t r a c e p t i o n
A f t e r t h e e a r l y
s t u d i e s , 7 i n c r e a s e d c o n f i d e n c e
i n
a n d
e x p e r i e n c e w i t h
n a t u r a l f a m i l y p l a n n i n g
m e t h o d s
t e n d e d t o
l e a d
t o p r o g r e s s i v e l y l o w e r
o v e r a l l
p r e g n a n c y
r a t e s .
The
r a t e s ,
h o w e v e r ,
r e m a i n
v a r i a b l e , d e p e n d i n g
o n
t h e s ta n d ar d o f t e a c h i n g a n d t h e m o t i v a t i o n t o
a v o i d
p r e g n a n c y . 2 4
2 8 3 9
A
s t u d y
i n
C h i l e
c o n f i r m e d
t h e
i m p o r t a n c e
o f
g o o d
i n i t i a l
n a t u r a l
f a m i l y p l a n n i n g
t e a c h i n g , e x p e r i e n c e d t e a c h e r s
a c h i e v i n g a p r e g n a n c y
r a t e
o f 4
7 , i n e x p e r i e n c e d t e a c h e r s
a c h i e v i n g a
r a t e
o f
1 6 - 8 . 2 8
S t u d i e s h a v e u n d er li n e d
t h e
i m p o r t a n c e
o f
m o t i v a t i o n ,
o n e
i n t e r n a t i o n a l
s t u d y
f i n d i n g
a
p r e g -
n a n c y r a t e
o f 4 - 1 3
i n
c o u p l e s
w i s h i n g
t o l i m i t t h e i r
f a m i l i e s
b u t
a
r a t e
o f
1 4 - 5 6
i n
c o u p l e s
w i s h i n g
o n l y
t o
s p a c e
t h e i r f a m i l i e s . 2 9
S t u d i e s
s u g g e s t
t h a t
m e t h o d s
c o m b i n i n g
s e v e r a l i n d i c a t o r s o f o v u l a t i o n y i e l d
l o w e r
p r e g n a n c y r a t e s . 3
T h e
c o s t
i s s u e h a s b e e n a d d r e s s e d ,
s t u d i e s f r o m L i b e r i a a n d
Z a m b i a s h o w i n g
p r e g n a n c y
r a t e s
o f
4 - 3
a n d 8 - 9
a n d u s e r c o s t s o f 4 0 a n d
3 0
r e s p e c t i v e l y . 3 5
A
s t u d y
o f
n a t u r a l
f a m i l y p l a n n i n g
i n
g e n e r a l p r a c t i c e
i n
t h e U n i t e d
K i n g d o m
a l s o f o u n d i t t o
b e
b y
f a r
t h e
c h e a p e s t
m e t h o d . 3 9
T h e l a r g e s t
n a t u r a l
f a m i l y p l a n n i n g s t u d y c o m b i n e d
e f f e c t i v e t e a c h i n g
w i t h
h i g h
m o t i v a t i o n a n d
s h o w e d
t h a t n a t u r a l f a m i l y
p l a n n i n g c a n
b e
e x t r e m e l y
e f f e c t i v e
i n
t h e
T h i r d
W o r l d . 3 3
T h e
s t u d y
w a s o f 1 9 8 4 3 p r e -
d o m i n a n t l y p o o r
women i n C a l c u t t a ,
52
H i n d u , 27
C l i n i c a l
i m p l i c a t i o n s
*
O v a r i a n
u l t r a s o n o g r a p h y
s h o w s
t h a t c e r v i c a l
m u c u s
s y m p t o m s
i d e n t i f y o v u l a t i o n w i t h
p r e c i s i o n
*
A c c o r d i n g
t o t h e
WHO,
women o f a l l c u l t u r a l
a n d e d u c a t i o n a l
b a c k g r o u n d s
c a n
l e a r n
t o
u s e
c e r v i c a l
m u c u s s y m p t o m
o b s e r v a t i o n
t o
r e c o g -
n i s e w h e n
t h e y o v u l a t e
* W o r l d w i d e
e v i d e n c e
s u g g e s t s
t h a t
m e t h o d s
o f b i r t h
c o n t r o l
u s i n g
a v o i d a n c e
o f
t h e f e r t i l e
p h a s e
i d e n t i f i e d
b y
o v u l a t i o n
s y m p t o m s
a r e
a s s o c i a t e d
w i t h
p r e g n a n c y r a t e s e q u i v a l e n t t o
t h o s e
w i t h
a r t i f i c i a l
c o n t r a c e p t i o n
*
F i n d i n g s
among s o m e
2 0 0 0 0
p o o r
women
i n
C a l c u t ta w i t h
a
p r e g n a n c y r a t e a p p r o a c h i n g
z e r o ,
c o m p l e m e n t e d b y
o t h e r s t u d i e s
i n t h e
d e v e l o p i n g
w o r l d ,
s u g g e s t
t h a t
t h e
m o t i v a t i o n
o f
p o v e r t y
may
b e
p a r t i c u l a r l y
a s s o c i a t e d w i t h
e f f e c t i v e
n a t u r a l
f a m i l y p l a n n i n g
*
A WHO
s t u d y
f o u n d t h a t
c o u p l e s
i n t h e
d e v e l o p i n g
w o r l d w e r e
s a t i s f i e d
w i t h
t h e
f r e q u e n c y
o f
i n t e r c o u r s e a s s o c i a t e d
w i t h n a t u r a l
f a m i l y
p l a n n i n g ,
w h i c h
i s
c h e a p
a n d
may
b e
e s p e c i a l l y
v a l u a b l e
i n
t h e
d e v e l o p i n g
w o r l d
M u s l i m , a n d 2 1
C h r i s t i a n . B e c a u s e o f p o v e r ty
m o t i v a t i o n
w a s
h i g h
b o t h among t h e
u s e r s a n d among
t h e w e l l
t r a i n e d
t e a c h e r s o f n a t u r a l
f a m i l y
p l a n n i n g .
The f a i l u r e r a t e w a s s i m i l a r
t o t h a t
w i t h t h e
c o m b i n e d
c o n t r a c e p t i v e
p i l l - 0 - 2 p r e g n a n c y / 1 0 0 women
u s e r s
y e a r l y . 3 3
The
r e s u l t s u g g e s t s
t h a t p o v e r t y a s t h e
m o t i v a t i o n c a n
g r e a t l y i m p r o v e t h e e f f e c t i v e n e s s o f
n a t u r a l f a m i l y
p l a n n i n g .
A s i m i l a r
r e s u l t , h o w e v e r , w a s
a c h i e v e d
i n
G e r m a n y
i n
a s t u d y
w i t h a
p r e g n a n c y
r a t e
o f 0 . 8 . 1 1
An I t a l i a n
s t u d y f o u n d
a n o v e r a l l p r e g n a n c y r a t e
o f
3 - 6 ,
a l l
t h e
p r eg n a n c i e s o c c u rr i n g
i n c o u p l e s
w i s h i n g
t o
s p a c e
b u t
n o t l i m i t
t h e i r
f a m i l i e s .
The
p r e g n a n c y
r a t e
w a s z e r o i n c o u p l e s who
w a n t e d
n o
m o r e
c h i l d r e n . 3 0
W i t h
o t h e r
German s t u d i e s
f i n d i n g
p r e g n a n c y r a t e s o f
1 - 8 3
a n d
2 . 3 , 3 6
a
s t u d y
i n
g e n e r a l
p r a c t i c e
i n
t h e
U n i t e d
K i n g d o m
f i n d i n g
a r a t e o f 2 - 7 , 3 9 a n d a s t u d y
among
3 0 0 3
i l l i t e r a t e
a n d s e m i l i t e r a t e
women
i n
I n d i a y i e l d i n g
a p r e g n a n c y r a t e
o f
2 O 0 4 3 7
t h e
a c c u m u l a t i n g d a t a
c o n f i r m
t h a t
n a t u r a l
f a m i l y p l a n n i n g c a n b e
a s e f f e c t i v e
a s a n y m e t h o d
o f
f a m i l y p l a n n i n g .
I m p l i c a t i o n s f o r t h e
T h i r d
W o r l d
I n
t h e
WHO
s t u d y
m o s t
c o u p l e s
i n t h e t h r e e
d e v e l o p i n g
c o u n t r i e s
who
p r a c t i s e d n a t u r a l f a m i l y
p l a n n i n g
w e r e
s a t i s f i e d
w i t h t h e
f r e q u e n c y o f i n t e r -
c o u r s e , w h e r e a s
i n t h e
t w o d e v e l o p e d c o u n t r i e s o n e
t h i r d o f s u b j e c t s a n d h a l f
o f t h e i r p a r t n e r s
who
p r a c t i s e d
t h e
m e t h o d
w o u l d h a v e p r e f e r r e d m o r e
f r e q u e n t
i n t e r c o u r s e . 2 7 I t m i g h t b e a r g u e d t h a t
n a t u r a l
f a m i l y
p l a n n i n g
b e i n g c h e a p , e f f e c t i v e , w i t h o u t
s i d e
e f f e c t s , a n d p o t e n t i a l l y
p a r t i c u l a r l y
e f f e c t i v e a n d
a c c e p t a b l e i n
a r e a s
o f
p o v e r t y
may
b e
t h e f a m i l y
p l a n n i n g m e t h o d o f
c h o i c e
f o r
t h e
T h i r d W o r l d . The
c a s e
f o r
a n d
a g a i n s t
t h i s may b e
a r g u e d a n d
d e b a t e d ,
b u t w h a t e v e r t h e s t a n d p o i n t
t h e r e i s
n o
d o u b t
t h a t i t
w o u l d b e
m o r e
e f f i c i e n t
f o r
t h e
o n g o i n g w o r l d d e b a t e
o n o v e r p o p u l a t i o n ,
r e s o u r c e s ,
e n v i r o n m e n t , p o v e r t y ,
a n d h e a l t h
t o b e c o n d u c t e d
a g a i n s t
a
b a c k g r o u n d
o f
t r u t h r a t h e r
t h a n
f a l l a c y .
I t
i s
t h e r e f o r e
i m p o r t a n t
t h a t
t h e
m i s c o n c e p t i o n
t h a t
C a t h o l i c i s m i s
s y n o n y m o u s
w i t h i n e f f e c t i v e
b i r t h
c o n t r o l
i s l a i d t o
r e s t .
U n d e r s t a n d i n g
t h e s i m p l e
f a c t s a b o u t t h e
s i g n s
o f
f e r t i l i t y
c o n f e r s
c o n s i d e r a b l e
p o w e r
t o
c o u p l e s
t o
c o n t r o l
t h e i r
f e r t i l i t y ,
f o r
a c h i e v i n g
a s
w e l l
a s
p r e v e n t -
i n g
c o n c e p t i o n .
The
w i d e s p r e a d
d i s s e m i n a t i o n
o f t h e s e
s i m p l e
f a c t s w o u l d
b e
u s e f u l e v e r y w h e r e
b u t
m i g h t
b e
o f
p a r t i c u l a r
v a l u e i n
t h e T h i r d W o r l d .
1 G o d l e e
F .
G o i n g b a c k w a r d s
i n R i o .
BM J
1 9 9 2 ; 3 0 4 : 1 5 2 5 .
2
P o o l e
J .
Time
f o r
t h e
V a t i c a n t o b e n d .
L a n c e t l 9 9 2 ; 3 3 9 : 1 3 4 0 - 1 .
3
F l y n n
AM . N a t u r a l
m e t h o d s
o f
c o n t r a c e p t i o n .
M a t e m a l
a n d
C h i l d H e a l t h
1 9 9 1 ; 1 6 : 1 4 8 - 5 3 .
4
B i l l i n g s E L ,
B i l l i n g s
n J ,
B r o w n
J B ,
B u r g e r
HG .
S y m p t o m s
a n d h o rm o na l
c h a n g e s a c c o m p a n y i n g
o v u l a t i o n .
L a n c e t
1 9 7 2 ; i : 2 8 2 - 4 .
5
F r a n c e
J T .
T h e d e t e c t i o n o f o v u l a t i o n
f o r
f e r t i l i t y
a n d
i n f e r t i l i t y .
I n : B o n n a r
J ,
e d . R e c e n t a d v a n c e s
i n o b s t e t r i c s a n d
g y n a e c o l o g y .
E d i n b u r g h : C h u r c h i l l
L i v i n g s t o n e ,
1 9 8 2 : 2 1 5 - 3 9 .
6
B r o m w i c h
P D .
P r o b l e m s
w i t h
s p e r m / c e r v i c a l
m u c u s i n t e r a c t i o n . P a r t
1 :
p a t h o p h y s i o l o g y .
B r i t i s h
J o u r n a l
o f
S e x u a l
M e d i c i n e
1 9 8 5 ; 1 2 : 1 2 4 - 5 .
7
F l y n n AM , L y n c h S S . C e r v i c a l
m u c u s
a n d i d e n t i f i c a t i o n
o f
t h e
f e r t i l e
p h a s e
o f
t h e
m e n s t r u a l
c y c l e .
B r J
O b s t e t G y n a e c o l
1 9 7 6 ; 8 3 : 6 5 6 - 9 .
8
D e p a r e s J ,
R y d e r R E J ,
W a l k e r
S M ,
S c a n l o n
MF, Norman CM .
O v a r i a n
u l t r a s o n o g r a p h y
h i g h l i g h t s
p r e c i s o n
o f
s y m p t o m s
o f o v u l a t i o n
a s
m a r k e r s
o f
o v u l a t i o n .
BM J
1 9 8 6 ; 2 9 2 : 1 5 6 2 .
9 V e s s e y
M,
L a w l e s s
M,
Y e a t e s
D .
E f f i c a c y
o f d i f f e r e n t
c o n t r a c e p t i v e
m e t h o d s .
L a n c e t
1 9 8 2 ; i : 8 4 1 - 2 .
1 0
M i l l s
A . B a r r i e r
c o n t r a c e p t i o n .
C l i n O b s t e t G y n e c o l 1 9 8 4 ; 1 : 6 4 1 - 6 0 .
1 1
L a i n g
J E .
N a t u r a l
f a m i l y
p l a n n i n g
i n t h e
P h i l i p p i n e s .
S t u d
F am
P l a n n
1 9 8 4 ; 1 5 : 4 9 - 5 5 .
1 2
D u n c a n
G ,
H a rp e r C ,
A s h w e l l
E ,
M a n t
D ,
B u c h a n
H ,
J o n e s L .
T e r m i n a t i o n
o f
p r e g n a n c y :
l e s s o n s f o r
p r e v e n t i o n .
B r i t i s h J o u r n a l
o f
F a m i l y P l a n n i n g
1 9 9 0 ; l S :
1
1 2 - 7 .
1 3
W e i s s m a n MC, F o l i a k i
L ,
B i l l i n g s E L , B i l l i n g s J n .
A
t r i a l o f t h e
o v u l a t i o n
m e t h o d o f
f a m i l y p l a n n i n g
i n
T o n g a .
L a n c e t
1 9 7 2 ; i i : 8 1 3 - 6 .
1 4 B a l l
M.
A
p r o s p e c t i v e
f i e l d t r i a l o f t h e o v u l a t i o n
m e t h o d o f
a v o i d i n g
c o n c e p t i o n .
E u r y
O b s t e t
G y n e c o l
R e p r o d
B i o l
1 9 7 6 ; 6 : 6 3 - 6 .
1 5
M a r s h a l l
J .
A
f i e l d
t r i a l o f t h e
b a s a l
b o d y
t e m p e r a t u r e m e t h o d
o f
r e g u l a t i n g
b i r t h s .
L a n c e t
1 9 6 8 ; i i : 8 - 1 0 .
1 6
M a r s h a l l
J .
C e r v i c a l - m u c u s a n d b a s a l
b o d y
t e m p e r a t u r e
m e t h o d o f
r e g u l a t i n g
b i r t h s . L a n c e t
1 9 7 6 ; i i : 2 8 2 - 3 .
1 7 P a r e n t e a u - C a r r e a u
S ,
L a n c t o t
C A ,
R i c e
F J . t t u d e
i n t e m a t i o n a l e
F a i r f i e l d
s u r
l e f f i c a c i t e
d e
l a
m e t h o d e s y m p t o - t h e r m i q u e
d e
r e g u l a t i o n
d e s n a i s s a n c e s .
R e s u l t a t s
C a n a d i e n s
c o m p a r e s
a u x
r e s u l t a t s
g l o b a u x .
L a V i e
M e d i c a l e
a u
C a n a d a
F r a n f a i s
1 9 7 6 ; 4 : 1 4 5 - 5 3 .
BM J VOLUME
3 0 7 1 8
S E P r E M B E R
1 9 9 3
7 2 5
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1 8
B i l l i n g s
n J .
N a t u r a l
f a m i l y
p l a n n i n g . L a n c e t
1 9 7 6 ; i i : 5 7 9 .
1 9
M a r s h a l l J . N a t u r a l f a m i l y p l a n n i n g .
L a n c e t
1 9 7 6 ; i i : 6 8 5 .
2 0 B i l l i n g s
J J .
N a t u r a l
f a m i l y p l a n n i n g . L a n c e t
1 9 7 6 ; i i : 9 6 9 .
2 1 M a r s h a l l
J .
N a t u r a l f a m i l y
p l a n n i n g . L a n c e t 1 9 7 6 i i :
1 0 8 5 .
2 2
R e i d
KM .
C h o i c e
o f m e t h o d . I n :
L o u d o n
N , e d .
H a n d b o o k
o f
f a m d y
p l a n n i n g .
E d i n b u r g h :
C h u r c h i l l
L i v i n g s t o n e ,
1 9 8 5 : 2 5 - 3 9 .
2 3 W o r l d H e a l t h
O r g a n i s a t i o n .
A
p r o s p e c t i v e
m u l t i c e n t r e t r i a l
o f t h e o v u l a t i o n
m e t h o d
o f n a t u r a l f a m i l y
p l a n n i n g .
I .
T h e t e a c h i n g p h a s e . F e r t d
S t e r i l
1 9 8 1 ; 3 6 : 1 5 2 - 8 .
2 4 W o r l d H e a l t h
O r g a n i s a t i o n .
A p r o s p e c t i v e m u l t i c e n t r e t r i a l o f t h e o v u l a t i o n
m e t h o d o f n a t u r a l
f a m i l y p l a n n i n g .
H . The
e f f e c t i v e n e s s p h a s e .
F e r t n S t e r i l
1 9 8 1 ; 3 6 : 5 9 1 - 8 .
2 5
W o r l d H e a l t h
O r g a n i s a t i o n .
A
p r o s p e c t i v e m u l t i c e n t r e
t r i a l o f t h e o v u l a t i o n
m e t h o d
o f
n a t u r a l
f a m i l y
p l a n n i n g .
I I I .
C h a r a c t e r i s t i c s
o f t h e m e n s t r u a l
c y c l e a n d
o f t h e f e r t i l e
p h a s e . F e r t d i
S t e r
1 9 8 3 ; 4 0 : 7 7 3 - 8 .
2 6
W o r l d
H e a l t h
O r g a n i s a t i o n .
A
p r o s p e c t i v e
m u l t i c e n t r e
t r i a l
o f
t h e
o v u l a t i o n
m e t h o d o f
n a t u r a l f a m i l y p l a n n i n g .
I V .
T h e
o u t c o m e o f
p r e g n a n c y .
F e r t i l
S t e r i l
1 9 8 4 ; 4 1 : 5 9 3 - 8 .
2 7
W o r l d
H e a l t h
O r g a n i s a t i o n .
p r o s p e c t i v e
m u l t i c e n t r e
t r i a l
o f t h e o v u l a t i o n
m e t h o d o f
n a t u r a l
f a m i l y
p l a n n i n g . V . P s y c h o s e x u a l
a s p e c t s .
F e r t i l
S t e r l
1 9 8 7 ; 4 7 : 7 6 5 - 7 2 .
2 8
P e r e z A , Z a b a l a
A,
L a r r a i n
A ,
W i d m e r S ,
N u n e z M, B a r a n d a
B ,
e t
a L
T h e
c l i n i c a l
e f f i c i e n c y
o f t h e
o v u l a t i o n
m e t h o d
B i l l i n g s ) .
R e v
C h i l O b s t e t
G i n e c o l
1 9 8 3 ; 4 8 : 9 7 - 1 0 2 .
2 9
R i c e
R J , L a n c t o t C A , G a r c i a - D e v e s a C .
E f f e c t i v e n e s s
o f t h e s y m p t o t h e r m a l
m e t h o d
o f
n a t u r a l
f a m i l y p l a n n i n g :
a n
i n t e m a t i o n a l
s t u d y .
I n t
J
F e r i l
1 9 8
1 ; 2 6 : 2 2 2 - 3 0 .
3 0
B a r b a t o
M, B e r t o l o t t i G . N a t u r a l m e t h o d s
f o r f e r t i l i t y c o n t r o l :
a
p r o s p e c t i v e
s t u d y .
I n t J F e r t i l 1 9 8 8 ; 3 3 ( s u p p l ) : 4 8 - 5 1 .
3 1
F r a n k - H e r m a n n P , Bremme
M,
R o s m u s
t ,
K u n k e l W. U s e - e f f e c t i v e n e s s
o f
a
s y m p t o t h e r m a l m e t h o d i n G e r m a n y .
I n :
S c h a i t o u i t s H ,
e d . P r o c e e d i n g s
o f
4 t h E u r o p e a n c o n g r e s s
I F F L P / F I D A F
V i e n n a , A u s t r i a . V i e n n a : I n s t i t u t
f i t
E h e u n d F a m i l i e , 1 9 8 7 : 2 7 - 4 5 .
3 2
B o n n a r J . N a t u r a l
f a m i l y
p l a n n i n g
i n c l u d i n g b r e a s t f e e d i n g .
I n :
M i s h e l l
DR,
e d .
A d v a n c e s
i n f e r t i l i t y r e s e a r c h .
Ne w Y o r k :
R a v e n
P r e s s ,
1 9 8 2 : 1 - 1 8 .
3 3
G h o s h A K ,
S a h a
S , C h a t t e r g e e
G .
S y m p t o t h e r m i a v i s a
v i s
f e r t i l i t y c o n t r o l .
J o u r n a l
o f O b s t e t r i c s
a n d
G y n a e c o l o g y o f I n d i a 1 9 8 2 ; 3 2 : 4 4 3 - 7 .
3 4 R o e t z e r J . S y m p t o t h e r m a l
m e t h o d s
o f n a t u r a l f a m i l y p l a n n i n g .
I n t e r n a t i o n a l
R e v i e w
o f N a t u r a l F a m i l y
P l a n n i n g
1 9 8 1 ; 5 : 2 0 0 - 2 .
3 5
K a m b i c R T ,
G r a y
R H ,
L a n c t o t C A , M a r t i n
MC,
W e s l e y R , C r e m i n s
R .
E v a l u a t i o n o f
n a t u r a l f a m i l y
p l a n n i n g
p r o g r a m s
i n
L i b e r i a a n d Z a m b i a .
Am J
O b s t e t G y n e c o l 1 9 9 1 ; 1 6 5 : 2 0 7 8 .
3 6
F r a n k - H e r r m a n n
P ,
F r e u n d l
G ,
B u r r
S ,
Bremme M, D o r i n g GK , G o d e h a r d t
E A J ,
e t
a l .
E f f e c t i v e n e s s a n d a c c e p t a b i l i t y o f t h e
s y m p t o t h e r m a l
m e t h o d o f
n a t u r a l
f a m i l y p l a n n i n g
i n
G e r m a n y .
Am J
O b s t e t
G y n e c o l
1 9 9 1 ; 1 6 5 : 2 0 5 2 - 4 .
3 7
D o r a i r a j
K.
T h e
m o d i f i e d
m u c u s m e t h o d
i n
I n d i a .
Am
J
O b s t e t
G y n e c o l
1 9 9 1 ; 1 6 5 : 2 0 6 6 - 7 .
3 8
K e l l y J .
A u d i t o f h e a l t h s e r v i c e s i n G u r a g e .
J
T r o p
P e d i a t r
1 9 9 2 ; 3 8 : 2 0 6 - 7 .
3 9
C l u b b EM, P y p e r CM ,
K n i g h t J .
A
p i l o t s t u d y
o n
t e a c h i n g
n a t u r a l
f a m i l y
p l a n n i n g i n g e n e r a l p r a c t i c e . I n : N a t u r a l
f a m i l y
p l a n n i n g : c u r r e n t
k n o w l e d g e
a n d
n e w
s t r a t e g i e s
f o r
t h e
1 9 9 0 s . W a s h i n g t o n , DC: G e o r g e t o w n U n i v e r s i t y ,
1 9 9 0 : 1 3 0 - 2 .
4 0
R y d e r R E J , D e p a r e s J , Norman C , W a l k e r S ,
S c a n l o n MF.
O v a r i a n
u l t r a s o n o g r a p h y a n d
t h e
p r e c i s i o n o f t h e s y m p t o m s o f o v u l a t i o n . C l i n S c i
1 9 8 5 ; 6 9 ( s u p p l 1 2 ) : 1 7 P .
A c c e p t e d 2 8 J u 1 y 1 9 9 3 )
E c o n o m i c E v a l u a t i o n a n d H e a l t h C a r e
C o s t s
a n d
c o s t - m i n i m i s a t i o n
a n a l y s i s
T h i s i s t h e
s e c o n d
i n a s e r i e s o f
a r t i c l e s
t h a t d e s c r i b e
t h e
w a y s
i n
w h i c h m e t h o d s
o f
e c o n o m i c
e v a l u a t i o n
m a y
b e u s e d t o
a s s e s s
t h e
e c o n o m i c
c o s t s
a n d
c o n s e q u e n c e s a s s o c i a t e d w i t h
d i f f e r e n t f o r m s o f h e a l t h c a r e
i n t e r v e n t i o n .
I n s t i t u t e f o r H e a l t h
P o l i c y
S t u d i e s , U n i v e r s i t y
o f
S o u t h a m p t o n ,
S o u t h a m p t o n
S0 9
5NH
R a y R o b i n s o n ,
p r o f e s s o r
o f
h e a l t h
p o l i c y
BM J
1 9 9 3 ; 3 0 7 : 7 2 6 - 8
Ray R o b i n s o n
W h a t e v e r
k i n d
o f e c o n o m i c e v a l u a t i o n
y o u p l a n
t o
u n d e r t a k e ,
t h e
c o s t s
must
b e a s s e s s e d . I n h e a l t h c a r e
t h e s e a r e f i r s t
o f a l l
d i v i d e d i n t o
c o s t s
b o r n e b y t h e
NH S ( l i k e d r u g s ) , b y p a t i e n t s a n d
t h e i r f a m i l i e s
( l i k e
t r a v e l ) , a n d
b y t h e r e s t o f s o c i e t y ( l i k e h e a l t h
e d u c a t i o n ) . N e x t t h e c o s t s h a v e
t o
b e
v a l u e d i n
m o n e t a r y t e r m s ; d i r e c t c o s t s , l i k e w a g e s ,
p o s e
l i t t l e
p r o b l e m , b u t
i n d i r e c t c o s t s
( l i k e
t i m e s p e n t
i n
h o s p i t a l )
h a v e t o
h a v e v a l u e s
i m p u t e d
t o t h e m . And
t h a t
i s n o t
a l l :
c o s t s
m u s t b e f u r t h e r s u b d i v i d e d
i n t o a v e r a g e ,
m a r g i n a l ,
a n d
j o i n t c o s t s , w h i c h
h e l p
d e c i s i o n s o n how
m u ch
o f
a
s e r v i c e s h o u l d b e
p r o v i d e d . C a p i t a l
c o s t s ( i n v e s t m e n t s
i n
p l a n t ,
b u i l d i n g s ,
a n d
m a c h i n e r y )
a r e a l s o
i m p o r t a n t ,
a s a r e
d i s c o u n t i n g a n d
i n f l a t i o n .
I n t h i s s e c o n d
a r t i c l e
i n
t h e s e r i e s R a y
R o b i n s o n
d e f i n e s
t h e
t y p e s
o f
c o s t s ,
t h e i r
m e a s u r e m e n t ,
a n d
how t h e y s h o u l d b e v a l u e d
i n
m o n e t a r y t e r m s .
C o s t - m i n i m i s a t i o n
a n a l y s i s i s
a n a p p r o p r i a t e e v a l u a -
t i o n m e t h o d t o
u s e
w h e n
t h e
c a s e
f o r a n
i n t e r v e n t i o n
h a s
b e e n
e s t a b l i s h e d
a n d
t h e
p r o g r a m m e s
o r
p r o c e -
d u r e s u n d e r c o n s i d e r a t i o n
a r e
e x p e c t e d t o
h a v e t h e
s a m e ,
o r
s i m i l a r ,
o u t c o m e s . I n t h e s e
c i r c u m s t a n c e s ,
a t t e n t i o n may f o c u s
o n t h e c o s t
s i d e o f
t h e e q u a t i o n
t o
i d e n t i f y
t h e l e a s t
c o s t l y
o p t i o n .
T h e
a n a l y s i s
o f
c o s t s t h a t
f o r m s
t h e
b a s i s o f c o s t -
m i n i m i s a t i o n
a n a l y s i s i s
common
t o
a l l f o r m s
o f
e c o n o m i c
e v a l u a t i o n , a n d
s o
t h e
f o l l o w i n g
d i s c u s s i o n
w i l l
a p p l y
a l s o t o
a p p l i c a t i o n s o f
c o s t - e f f e c t i v e n e s s ,
c o s t - u t i l i t y ,
a n d c o s t - b e n e f i t a n a l y s i s .
Which c o s t s
s h o u l d
b e
i n c l u d e d ?
I f
t h e e v a l u a t i o n
i s
b e i n g
m a d e
f r o m
t h e w i d e s t
p e r s p e c t i v e - n a m e l y ,
t h e
v i e w p o i n t
o f
s o c i e t y
a s a
w h o l e - t h e n
t h r e e
m a i n
c a t e g o r i e s
o f
c o s t s
m u s t
b e
c o n s i d e r e d :
* H e a l t h
s e r v i c e c o s t s
*
C o s t s
bome
b y p a t i e n t s
a n d
t h e i r
f a m i l i e s
*
E x t e m a l c o s t s bome
b y
t h e r e s t
o f
s o c i e t y .
Summary
* C o s t - m i n i m i s a t i o n a n a l y s i s
s h o u l d
b e u s e d w h e n
t h e o u t c o m e s o f a l t e r n a t i v e
p r o g r a m m e s
a r e
t h e
s a m e
o r s i l m i l a r
* From a
s o c i e t a l p e r s p e c t i v e ,
c o s t s
i n c l u d e :
h e a l t h
s e r v i c e
c o s t s ,
c o s t s
b o r n e b y
p a t i e n t s
a n d
t h e i r f a m i l i e s
a n d e x t e r n a l
c o s t s
b o rn e b y t h e r e s t o f s o c i e t y
* C o s t s
s h o u l d r e f l e c t o p p o r t u n i t y c o s t s
a n d
may
b e
v a l u e d i n t e r m s
o f
m a r k e t
p r i c e s
o r s h a d o w p r i c e s
*
M a r g i n a l
c o s t s
a r e
o f t e n
l o we r t h a n a v e r a g e c o s t s
*
D i s c o u n t i n g
i s n e c e s s a r y t o e x p r e s s c o s t s
o n
a
common b a s i s ( p r e s e n t v a l u e s )
w h e n
t h e y
a r e i n c u r r e d
a t d i f f e r e n t p o i n t s
i n
t i m e
*
M e t h o d s f o r t a k i n g a c c o u n t o f i n f l a t i o n
n e e d
t o
d i s t i n g u i s h
b e t w e e n
c h a n g e s
i n t h e g e n e r a l
p r i c e
l e v e l
a n d c h a n g e s
i n
r e l a t i v e p r i c e s
HEALTH
SERVICE COSTS
T h e s e
w i l l
i n c l u d e
s t a f f
t i m e ,
m e d i c a l
s u p p l i e s
( i n c l u d i n g d r u g s ) ,
h o t e l s e r v i c e s ,
u s e
o f
c a p i t a l
e q u i p -
m e n t , a n d o v e r h e a d s
s u c h a s
h e a t i n g a n d l i g h t i n g .
T h e s e i t e m s
may b e d i v i d e d
i n t o
v a r i a b l e c o s t s
w h i c h
v a r y a c c o r d i n g t o t h e
l e v e l o f a c t i v i t y ( f o r e x a m p l e ,
s t a f f t i m e ) a n d
f i x e d
c o s t s
w h i c h a r e
i n c u r r e d w h a t e v e r
t h e l e v e l o f
a c t i v i t y ( f o r e x a m p l e ,
h e a t i n g
a n d
l i g h t i n g ) .
I n
t h e l o n g r u n , p r a c t i c a l l y
a l l
c o s t s b e c o m e
v a r i a b l e
b e c a u s e t h o s e t h a t
a r e f i x e d
i n t h e
s h o r t r u n
may b e
v a r i e d - f o r
e x a m p l e , b y o p e n i n g
a n d
c l o s i n g w a r d s ,
a n d
b y
b u i l d i n g
new
h o s p i t a l s .
I n e c o n o m i c e v a l u a t i o n
a l l
h e a l t h s e r v i c e c o s t s - b o t h f i x e d
a n d
v a r i a b l e - a r e
r e f e r r e d
t o
a s d i r e c t c o s t s .
COSTS BORNE
BY
PATIENTS AND
TH IR
FAMILES
T h e s e
w i l l
i n c l u d e
o u t
o f
p o c k e t
e x p e n s e s
s u c h
a s
t r a v e l ,
a n d
a n y
c o s t s
r e s u l t i n g
f r o m
c a r i n g
a c t i v i t i e s
u n d e r t a k e n b y
t h e
f a m i l y .
T h e s e
a r e b o t h
d i r e c t c o s t
i t e m s . I n
a d d i t i o n ,
t h e r e may a l s o
b e i n d i r e c t
c o s t s
s u c h
a s
i n c o m e l o s t
b e c a u s e o f a b s e n c e f r o m
w o r k
7 2 6 BMJ
VOLUME 30 7
1 8
SEPTEMBER1993
