Marquette Method & NFP Research

Background: The aim was to compare the efficacy and acceptability of two Internet-supported fertility-awareness-based methods of family planning.

Study design: Six hundred and sixty-seven women and their male partners were randomized into either an electronic hormonal fertility monitor (EHFM) group or a cervical mucus monitoring (CMM) group. Both groups utilized a Web site with instructions, charts and support. Acceptability was assessed online at 1, 3 and 6 months. Pregnancy rates were determined by survival analysis.

Results: The EHFM participants (N=197) had a total pregnancy rate of 7 per 100 users over 12 months of use compared with 18.5 for the CMM group (N=164). The log rank survival test showed a significant difference (p<.01) in survival functions. Mean acceptability for both groups increased significantly over time (p<.0001). Continuation rates at 12 months were 40.6% for the monitor group and 36.6% for the mucus group.

Conclusion: In comparison with the CMM, the EHFM method of family planning was more effective. All users had an increase in acceptability over time. Results are tempered by the high dropout rate.

Fehring RJ, Schneider M, Raviele K, Rodriguez D, Pruszynski J. Randomized comparison of two Internet-
supported fertility-awareness-based methods of family planning. Contraception. 2013 Jul;88(1):24-30. DOI:
10.1016/j.contraception.2012.10.010. Epub 2012 Nov 12. PMID: 23153900.

Objective: To determine the efficacy of using natural family planning (NFP) methods to avoid unintended pregnancy among women of perimenopause age (i.e., age 40-55 years).

Design: A secondary analysis of subset data from two prospective observational cohort studies.

Setting: A university based in-person and online NFP service program.

Participants: One hundred and sixty couples who used either a website or an in-person NFP service to learn how to avoid pregnancy from January 2001 to November 2012.

Methods: A prospective 12-month effectiveness study among 160 women (between ages 40-55) who used NFP to avoid pregnancy. The women used either a hormonal fertility monitor, cervical mucus monitoring, or both to estimate the fertile phase of their menstrual cycles. Survival analysis was used to determine the pregnancy rate over 12 months of use.

Results: There were a total of five unintended pregnancies among the participants. The typical use pregnancy rate was six per 100 women over 12 months. The monitor alone participants (n = 35) had a 12-month pregnancy rate of three, the participants (n = 73) who used mucus alone had a pregnancy rate of four, and the participants (n = 42) who used the fertility monitor plus mucus had a pregnancy rate of six.

Conclusion: Natural family planning methods can be effective for older women to avoid an unintended pregnancy with correct use and adequate instructions. The pregnancy rate most likely was affected by diminished fertility and motivation to limit family size.

Fehring RJ, Mu Q. Cohort efficacy study of natural family planning among perimenopause age women. J Obstet
Gynecol Neonatal Nurs. 2014 May-Jun;43(3):351-8. DOI: 10.1111/1552-6909.12307. Epub 2014 Apr 22. PMID:
24754305.

Objective: To determine the effectiveness of achieving pregnancy with focused intercourse in the fertile window identified using natural fertility indicators.

Methods: 24-cycle prospective effectiveness study.

Setting: A North American web-based fertility monitoring service.

Participants: 256 North American women aged 20-43 (mean age 29.2 years) seeking to achieve pregnancy.

Intervention: Participants identified their fertile window with either electronic hormonal fertility monitoring or cervical mucus monitoring, or both, and recorded their observations on an online fertility tracking system.

Main outcome measures: Pregnancies were validated by nurses with an online self-assessed pregnancy evaluation form. Survival analysis was used to determine pregnancy rates.

Results: There were 150 pregnancies among the 256 participants with an overall pregnancy rate of 78 per 100 women over 12 menstrual cycles. There were 54 pregnancies (68%) among the 80 women using the fertility monitor, 11 pregnancies (46%) among the 24 women using mucus monitoring, and 90 (63%) among the 143 women using both mucus and monitor. The 12-cycle pregnancy rates per 100 women were 83 (monitor group), 72 (mucus group), and 75 (mucus and monitor group). Pregnancy rates reached 100% at 24 cycles of use for those women using the hormonal fertility monitor.

Conclusion: Use of the hormonal fertility monitor alone seems to offer the best natural estimate of the fertile phase of the menstrual cycle for women wishing to achieve a pregnancy. Focusing intercourse through 24 menstrual cycles can be beneficial for achieving pregnancy.

Bouchard TP, Fehring RJ, Schneider MM. Achieving Pregnancy Using Primary Care Interventions to Identify the
Fertile Window. Front Med (Lausanne). 2018 Jan 9;4:250. DOI: 10.3389/fmed.2017.00250. PMID: 29376054;
PMCID: PMC5767237.

Objective: To determine variability in the phases of the menstrual cycle among healthy, regularly cycling women.

Design: A prospective descriptive study of a new data set with biological markers to estimate parameters of the menstrual cycles.

Participants: One hundred forty one healthy women (mean age 29 years) who monitored 3 to 13 menstrual cycles with an electronic fertility monitor and produced 1,060 usable cycles of data. MEASURES AND OUTCOMES: Variability in the length of the menstrual cycle and of the follicular, fertile, and luteal phases, and menses. The estimated day of ovulation and end of the fertile phase was the peak fertility reading on the monitor (i.e., the urinary luteinizing hormone surge).

Results: Mean total length was 28.9 days (SD = 3.4) with 95% of the cycles between 22 and 36 days. Intracycle variability of greater than 7 days was observed in 42.5% of the women. Ninety-five percent of the cycles had all 6 days of fertile phase between days 4 and 23, but only 25% of participants had all days of the fertile phase between days 10 and 17.

Conclusions: Among regularly cycling women, there is considerable normal variability in the phases of the menstrual cycle. The follicular phase contributes most to this variability.

Fehring RJ, Schneider M, Raviele K. Variability in the phases of the menstrual cycle. J Obstet Gynecol Neonatal
Nurs. 2006 May-Jun;35(3):376-84. DOI: 10.1111/j.1552-6909.2006.00051.x. PMID: 16700687.

Background: Menstrual cycle function may continue to be altered after discontinuation of oral contraceptives (OC). Few studies have been published on the effects of recent OC use on menstrual cycle parameters; none have examined characteristics of the menstrual flow or the quality of cervical mucus. The purpose of this retrospective matched cohort study is to assess biomarkers of the menstrual cycle after discontinuation of OCs.

Methods: Among a sample of women who daily recorded observations of menstrual cycle biomarkers, 70 women who had recently discontinued OCs were randomly matched by age and parity with 70 women who had not used OCs for at least 1 year. Outcomes investigated included overall cycle length, length of the luteal phase, estimated day of ovulation, duration of menstrual flow, menstrual intensity, and mucus score. Differences between recent OC users and controls were assessed using random effects modeling.

Results: Recent OC users had statistically significantly lower scores for mucus quality for cycles 1 and 2. Additionally, OC users had a later estimated day of ovulation that was statistically significant in cycle 2 and a decreased intensity of menstrual flow that was significant in the first four cycles (difference = -0.48 days). In random effects modeling, all these parameters were significantly different for the first six cycles combined.

Conclusions: Menstrual cycle biomarkers are altered for at least two cycles after discontinuation of OCs, and this may help explain the temporary decrease in fecundity associated with recent OC use.

Nassaralla CL, Stanford JB, Daly KD, Schneider M, Schliep KC, Fehring RJ. Characteristics of the menstrual cycle
after discontinuation of oral contraceptives. J Womens Health (Larchmt). 2011 Feb;20(2):169-77. DOI:
10.1089/jwh.2010.2001. Epub 2011 Jan 10. PMID: 21219248; PMCID: PMC7643763.

Obesity and high body mass index (BMI) are known to be risks for anovulation and infertility. Little is known about how BMI levels affect parameters of the menstrual cycle. The purpose of this study was to determine the influence of BMI on parameters of the menstrual cycle and the likelihood for ovulation. The participants in this study were 244 women between the ages of twenty and fifty-four (mean thirty years) who charted from one to thirty-six menstrual cycles (mean seven cycles) for a total of 2,035 cycles. Urinary luteinizing hormone (LH) threshold tests were used to estimate the day of ovulation and the lengths of the follicular and luteal phases. The 244 participants were classified as normal weight with a BMI of 18.5-24.9 kg/m2 (N = 141), overweight with a BMI of 25-29.9 kg/m2 (N = 67), and obese with a BMI of 30 kg/m2 or greater (N = 36). One-way ANOVA indicated that there was a significant difference between groups in length of the luteal phase (F = 4.62, p < 0.01) and length of menses (F = 3.03, p < 0.05). Odds ratio indicated that the combined obese and overweight group was 34 percent less likely to have a positive detected urinary LH surge. We concluded that obesity might contribute to infertility by shortening the luteal phase and decreasing the probability of ovulatory menstrual cycles.

Lasquety MG, Rodriguez D, Fehring RJ. The Influence of BMI Levels on Phases of the Menstrual Cycle and
Presumed Ovulation. Linacre Q. 2012 Nov;79(4):451-459. DOI: 10.1179/002436312804827082. Epub 2012 Nov 1.
PMID: 30082988; PMCID: PMC6027099.

Objective: To explore the relationships among young women’s demographic characteristics, their self-perceived and actual knowledge about fertility, and their fertility health risk factors.

Design: A quantitative, cross-sectional study.

Setting: Online survey.

Participants: Young women between the ages of 18 and 24 years (N = 342).

Methods: We used an online survey to collect data from young women regarding their demographic characteristics, their self-perceived and actual knowledge about fertility, and their fertility health risk factors. We used multiple linear regression to explore the relationships among these factors.

Results: Participants were mainly White, had some form of college education, and used a variety of contraception methods. Regression modeling indicated that participants’ self-perceived knowledge and actual knowledge about fertility and their methods of contraception were significantly associated with their fertility health risks (R² = .13, p < .001). Participants who had higher actual scores of knowledge about fertility and who used fertility awareness methods had fewer self-reported fertility health risk factors. A greater level of self-perceived knowledge about fertility was associated with more fertility health risk factors. Age, education level, and pregnancy history were not significantly associated with fertility health risks.

Conclusion: Our findings provide evidence that knowledge about fertility is important to enhance fertility self-care for young women. The significant relationship between young women’s knowledge about fertility and their fertility health risks highlights the need to assess their knowledge and teach them about fertility as important components of preconception care. Such education may help them avoid fertility health risks and protect young women’s current and future fertility.

Mu Q, Hanson L, Hoelzle J, Fehring RJ. Young Women&#39;s Knowledge About Fertility and Their Fertility Health Risk
Factors. J Obstet Gynecol Neonatal Nurs. 2019 Mar;48(2):153-162. DOI: 10.1016/j.jogn.2018.12.009. Epub 2019
Jan 24. PMID: 30684446.

A recent survey conducted by the American Academy of Natural Family Planning (AANFP) found that over 55% of Catholic hospitals surveyed either provide or would like to provide some form of Natural Family Planning (NFP) services. In addition, over 60% of the respondents felt that NFP should be part of the mission of a Catholic hospital. This recent survey was conducted by the AANFP in order to determine the use ofNFP in Catholic hospitals, (i.e., whether NFP is provided, types of NFP methods taught, teaching standardization and methodologies used, qualifications of NFP teachers, and the ethics of NFP services). This article is a report on that survey.

Natural Family Planning and Catholic Hospitals: A National Survey Richard J. Fehring, PhD, RN and Carl Werner, MD

Making decisions about achieving and avoiding pregnancy and the methods used to attain those ends are some of the most central decisions during a couple’s reproductive life. Health professionals (especially professional nurses) are often consulted to aid couples in their reproductive decisions and provide couples with choices of reproductive control. Information provided on family planning choices, however, is often limited and usually involves issues of effectiveness to avoid pregnancy, convenience, health risks, and life-style preferences.l,2 Little information is provided on how family planning methods compare on psychological, spiritual, and social well-being variables. One method of family planning that needs further study on these variables is Natural Family Planning (NFP). The purpose of this study was to describe how NFP influenced the intimacy, self-esteem, and the spiritual well-being of couples who used NFP to avoid pregnancy for at least a one year period. A secondary purpose was to describe and compare the intimacy, self-esteem and spiritual well-being of couples who stopped using NFP and who have used contraception for at least a year.

Spiritual Well-Being, Self-Esteem and Intimacy Among Couples Using Natural Family Planning
The Linacre Quarterly
Richard Fehring, Marquette University
Donna M Lawrence, Marquette University

Perinatal health professionals are in key positions to either promote or dissuade the use of Natural Family Planning (NFP). The purpose of this article is to describe a survey conducted with perinatal physicians and nurses on their knowledge and professional use of NFP. Four hundred and fifty physicians and nurses (150 MDs and 300 RNs) were sent a questionnaire on the use of and knowledge of NFP. One hundred sixty-six (or 37%) returned the completed questionnaires. Fifty-two percent of the nurses who returned the questionnaires and 48% of the physicians indicated they were taught about NFP in basic (generic) medical or nursing school. The average lecture time spent on the subject in either nursing or medical school was less than one hour. The majority learned about NFP through self-education or on-the-job training. Only four (1 RN and 3 MDs) are certified to teach NFP. Fifty-three percent of the nurses and 44% of physicians would not advise the use of NFP to avoid pregnancy. The most frequent reasons given for not promoting the use of NFP to either avoid or achieve pregnancy were that it is not effective, not natural, too difficult to learn, better methods are available, and it only works for highly motivated educated women.

A Study of Physicians’ and nurses’ knowledge and use of natural family planning. The Linacre Quarterly, (1995):
Richard Fehring, Marquette University

The purpose of this study was to describe and assess certified nurse-midwives’ (CNMs) knowledge and promotion of two modalities for child spacing, natural family-planning (NFP) and the lactational amenorrhea method (LAM). One thousand two hundred CNMs were randomly selected from a national membership list and mailed a 24-item questionnaire on NFP and LAM. Of the 514 respondents (42.8% return rate), 450 (87.5%) were currently practicing as CNMs. Respondents had an average age of 46 years, with an average of 10 years of practice. CNMs ranked NFP as the ninth most used and the eighth most effective family-planning method in their practice, with an average perceived method-effectiveness of 88% and use-effectiveness of 70%. Although most respondents felt somewhat prepared during their education program to provide NFP, only 22% would offer NFP as a family-planning option for child spacing.

Nurse-Midwives’ Knowledge and Promotion of Lactational Amenorrhea and Other Natural Family-Planning
Methods for Child Spacing
Journal of Midwifery &amp; Women’s Health
Richard Fehring, Marquette University
Lisa Hanson, Marquette University
Joseph B. Stanford, University of Utah

Over 30 years ago the founders of the Christian Family Movement (CFM), a worldwide Catholic family action group, conducted a survey to investigate the marital effects of practicing “rhythm.” Their final report indicated that many participants felt that periodic abstinence was harmful to their marriage and caused spiritual and religious distress. The CFM survey results were thought to have been influential in convincing the 1966 Papal Birth Control Commission to recommend a change in church teaching. The purpose of this paper is to report a re-analysis of the 1966 archived data (in the light of the Papal Encyclical Humane Vitae–On the Regulation of Birth) and to compare that study with responses from married couples using modern methods of NFP, i.e., methods that purport to be more effective and to have fewer days of periodic abstinence. This paper will provide an examination of the original study within its historical context and report on the responses relating to spirituality from the 1966 couples in comparison with couples currently practicing periodic abstinence through the Billings Ovulation Method.

Nurse-Midwives’ Knowledge and Promotion of Lactational Amenorrhea and Other Natural Family-Planning
Methods for Child Spacing
Journal of Midwifery &amp; Women’s Health
Richard Fehring, Marquette University
Lisa Hanson, Marquette University
Joseph B. Stanford, University of Utah

Little is known about how using various methods of birth control affect marital relationships and sexual dynamics. Few providers have made couples’ dynamics a consistent area of follow-up. Early research indicated that natural family planning (NFP) was associated with psychological distress and that it affected marital relationships negatively (Crowley & Crowley, 1966; Marshall & Rowe, 1970).

Crowley and Crowley (1966) served as members of the Papal Birth Control Commission to study whether the Roman Catholic Church should change its position on family planning. The Crowleys surveyed 266 couples in the United States of America (USA) and asked whether the calendar rhythm method had helped or harmed their marriages. They received 158 responses, a 59% return rate. Responses were primarily negative; with 74% saying NFP had harmed their marriages.

Couples reported difficulty with abstinence, loss of spontaneity, arguments, and increased fear of pregnancy. Similarly, Marshall and Rowe (1970) administered a detailed questionnaire to 502 couples who were currently using basal body temperature (BBT) and found that 48% of the respondents experienced some psychological stress from periodic abstinence, with unfavorable effects on their marital relationships. Couples who participated in these earlier studies used older forms of NFP, including calendar rhythm and BBT. Since then, newer methods of NFP have been designed in which women recognize and document changes in cervical mucous secretions as the primary indication of fertility (Billings, Billings, & Caterinich, 1989; Hilgers, Daily, Hilgers, & Prebil, 1982). Modern methods require shorter periods of abstinence and are more effective. However, they still require partners to cooperate with up to 7-12 days of abstinence per month.

McCusker (1977) and Borkman and Shivanandan (1984) interviewed NFP-using couples and identified enhanced marital relationships, including improvements in communication, body, and fertility awareness, intimacy, shared responsibility, peace of mind, confidence, self-control, and spiritual wellbeing. Using a written questionnaire, Fehring and Lawrence (1994) interviewed 40 couples who used NFP and compared them with 40 couples who had switched to other methods. The authors identified positive and negative themes reported by both groups in the areas of intimacy, self-esteem, and spiritual well-being. Couples who continued using NFP rated significantly higher on spiritual well-being than did those who had switched to other methods.

Many recent researchers have measured satisfaction with NFP. In Boys’ (1988) sample of 424 women, 72% reported method satisfaction. In a World Health Organization (1987) study in five countries (New Zealand, Ireland, Philippines, India, and EI Salvador), men and women participants reported 97% and 98% satisfaction respectively. Additionally, 83% of the women and 53% of the men reported no difficulty with abstinence. Although the majority of NFP-users in the survey reported method satisfaction, little recent work has been reported concerning effects on marital relationships. Also, few studies have included open-ended questions to allow participants to use their own words.

Promoters of NFP have stated that abstaining periodically from intercourse and using other expressions of sexual intimacy strengthened marriages {Billings et aI., 1989; Hilgers et al., J982}. Several positive effects of practicing NFP have been cited in the literature (Borkman & Shivanandan, 1984; Fehring & Lawrence, 1994; McCusker, 1977; Tortorici, 1979), including improvements in understanding human reproduction, communication, self-control, intimacy, appreciation of intercourse, and spiritual well-being. However, periodic abstinence and daily monitoring of menstrual cycles were stressful to couples’ relationships, and lack of spontaneity, difficulty with abstinence, and fear of pregnancy were common complaints (Hefernan, 1977). Therefore, further study was needed. The purpose of this study was to identify the effects of modern NFP methods on marital dynamics by asking couples the same open-ended questions the Crowleys posed in the 1960s. 

VandeVusse, Leona; Hanson, Lisa; Fehring, Richard; Newman, Amy; and Fox, Jaime, “Couples’ Views of the Effects of Natural Family Planning on Marital Dynamics” (2004). College of Nursing Faculty Research and Publications. 9. 

Purpose: Mutual motivation is recognized as essential for effective behavioral methods of family planning. Few studies have studied this factor in family planning efficacy. The purpose of this study was to determine the influence of mutual motivation on unintended pregnancy rates of couples who used natural family planning (NFP) methods to avoid pregnancy.

Study Design and Methods: Using an online taught NFP method, 358women and ( their male partners) indicated “how much” and “how hard” they wished to avoid pregnancy on a scale of 0- 10 before each menstrual cycle charted over 12 month of use. This motivation scale is used in the National Survey of Family Growth as a measure of motivation. All pregnancies were verified with an online pregnancy evaluation and urine based pregnancy test. A combined motivation score was used in analysis.

Results: There were 28 pregnancies among the low motivation participants (N=60) and 16 among the high motivation participants (N=298). At 12 months of use, there were 75 pregnancies per 100 users for the low motivation group and only 8 for the high motivation group. There was an 80% greater likelihood of a pregnancy with the low motivation group (χ2 = 25.5, p < .001) OR = 1.80; 95% CI = 1.61-1.90).

Clinical Implications: High motivation to avoid pregnancy by both the female user of a behavioral method of family planning and her male partner is required for high efficacy. Assessing motivation of both the woman and her male partner before prescribing NFP methods is recommended.

Influence of Motivation on the Efficacy of Natural Family Planning
MCN, The American Journal of Maternal/Child Nursing
Richard J. Fehring, Marquette University
Mary Schneider, Marquette University
Mary Lee Barron, Saint Louis University
Jessica E. Pruszynski, Medical College of Wisconsin

There are few studies that have investigated the spiritual problems of couples practicing natural family planning (NFP). The purpose of this paper is to analyze the spiritual problems and interventions of couples who were taught NFP by means of a professional online Web-based support system. Responses from this online system and its forums were categorized according to spiritual responses, spiritual problems, and spiritual interventions to the practice of NFP. Themes addressed included spiritual care in regards to decisions about the transmission of new life, difficulties in dealing with chastity and abstinence, bioethical problems related to pregnancy and illness, end of the reproductive life decisions, ethical treatment of women’s health problems, sacrifice, and personal and relational struggles. Online community support, help in building confidence in NFP methods, and bioethicist referral are key interventions. The complexity of these spiritual responses, problems, and appropriate interventions require the expertise of health professionals in cooperation with bioethicists. We concluded that NFP can be viewed as both a spiritual practice and a means of spiritual growth.

Spiritual Care of Couples Practicing Natural Family Planning
The Linacre Quarterly
Richard Fehring, Marquette University
Dana Rodriguez, Marquette University

Introduction: The length of periodic abstinence, due to overestimation of the fertile phase of the menstrual cycle, is often a cause for dissatisfaction, discontinuation, and user error with natural family planning (NFP) methods. The objective of this research was to compare the length of required abstinence (ie, estimated fertility) and coital frequency between 2 NFP methods.

Methods: This was an analysis of data from a 12-month prospective comparison study in which participants were randomized into either an electronic hormonal fertility monitor (EHFM) group or a cervical mucus monitoring (CMM) group—both of which included a fertility algorithm as adouble check for the beginning and end of the estimated fertile window. The number of days of estimated fertility and coitus was extracted from each menstrual cycle of data, and t tests were used to compare the means of these 2 variables between the 2 NFP methods.

Results: The study involved 197 women (mean [SD] age 29.7 [5.4]) who used the EHFM to estimate the fertile window and 160 women (mean [SD] age 30.4 [5.3]) who used CMM to estimate the fertile window. They produced 1,669 menstrual cycles of data. After 12 months of use, the EHFM group had statistically fewer days of estimated fertility than the CMM group (mean [SD] days, 13.25 [2.79] vs 13.68 [2.99], respectively; t = 2.07; P = .039) and significantly more coitus (mean [SD] coital acts, 4.22 [3.16] vs 4.05 [2.88], respectively; t = 1.17; P = .026).

Discussion: The use of the EHFM seems to provide more objectivity and confidence in self-estimating the fertile window and using nonfertile days for intercourse when avoiding pregnancy.

Comparison of Abstinence and Coital Frequency Between 2 Natural Methods of Family Planning
Journal of Midwifery &amp; Women’s Health
Richard J. Fehring, Marquette University
Mary Schneider, Marquette University

Objectives: During normal menstrual cycles, serum levels of progesterone vary widely between cycles of same woman and between women. This study investigated the profiles of pregnanediol during the luteal phase.

Methods: Data stemmed from a previous multicenter prospective observational study and concerned 107 women (who contributed 326 menstrual cycles). The study analyzed changes in observed cervical mucus discharge, various hormones in first morning urine, and serum progesterone. Transvaginal ultrasonography and cervical mucus helped identifying the day of ovulation. Changes in pregnanediol glucuronide levels during the luteal phase were examined and classified according to the length of that phase, a location parameter, and a scale parameter. Associations between nine pregnanediol glucuronide profiles and other hormone profiles were examined.

Results: Low periovulatory pregnanediol glucuronide levels and low periovulatory luteinizing hormone levels were associated with delayed increases in pregnanediol glucuronide after ovulation. That ‘delayed increase profile’ was more frequently associated with cycles with prolonged high LH levels than in cycles with rapid pregnanediol glucuronide increases. A ‘plateau-like profile’ during the luteal phase was associated with longer cycles, cycles with higher estrone-3-glucuronide and pregnanediol glucuronide during the preovulatory phase, and cycles with higher periovulatory pregnanediol glucuronide levels.

Conclusions: Distinct profiles of urinary progesterone levels are displayed during the luteal phase. These profiles relate to early hormone changes during the menstrual cycle. In everyday clinical practice, these findings provide further evidence for recommending progesterone test seven days after the mucus peak day. The search for other correlations and associations is underway.

Abdullah S, Bouchard T, Leiva R, Boehringer H, Iwaz J, Ecochard R. Distinct urinary progesterone metabolite profiles
during the luteal phase. Hormone Mol Biology Clin Investigation 2022;0. https://doi.org/10.1515/hmbci-2022-
0065.

Objective: Explore potential relationships between preovulatory, periovulatory, and luteal-phase characteristics in normally cycling women.

Design: Observational study.

Setting: Eight European natural family planning clinics.

Patient(s): Ninety-nine women contributing 266 menstrual cycles.

Intervention(s): The participants collected first morning urine samples that were analyzed for estrone-3 glucuronide (E1G), pregnanediol-3- alpha-glucuronide (PDG), follicle stimulating hormone (FSH), and luteinizing hormone (LH). The participants underwent serial ovarian ultrasound examinations.

Main Outcome Measure(s): Four outcome measures were analyzed: short luteal phase, low mid-luteal phase PDG level (mPDG), normal then low luteal PDG level, low then normal luteal PDG level.

Results: A long preovulatory phase was a predictor of short luteal phase, with or without adjustment for other variables. A high periovulatory PDG level was a predictor for short luteal phase as well as normal then low luteal PDG level. A low periovulatory PDG level predicted low mPDG and low then normal luteal PDG level, with or without adjustment for other variables. A small maximum follicle predicted normal then low luteal PDG level, with or without adjustment for other variables. The relationship between small maximum follicle size and short luteal phase or small maximum follicle size and low mPDG was no longer present when the regression was adjusted for certain characteristics. A younger age at menarche and a high body mass index were both predictors of low mPDG.

Conclusion: Luteal phase abnormalities exist over a spectrum where some ovulation disorders may exist as deviations from the normal ovulatory process.This study confirms the negative impact of a small follicle size on the quality of the luteal phase. The occurrence of normal then low luteal PDG level is confirmed as a potential sign of luteal phase abnormality.

Abdullah SH, Bouchard TP, Leiva RA, Boyle P, Iwaz J, Ecochard R. Hormonal Predictors of Abnormal Luteal Phases in
Normally Cycling Women. Frontiers in Public Health 2018;6:144. https://doi.org/10.3389/fpubh.2018.00144.

Objective: To characterize the variability of hormonal profiles during the luteal phase in normal cycles.

Design: Observational study.

Setting: Not applicable.

Patient(s): Ninety-nine women contributing 266 menstrual cycles.

Intervention(s): The women collected first morning urine samples that were analyzed for estrone-3-glucuronide, pregnanediol-3-alpha-glucuronide (PDG), FSH, and LH. The women had serum P tests (twice per cycle) and underwent ultrasonography to identify the day of ovulation.

Main outcome measure(s): The luteal phase was divided into three parts: the early luteal phase with increasing PDG (luteinization), the midluteal phase with PDG ≥10 μg/mg Cr (progestation), and the late luteal phase (luteolysis) when PDG fell below 10 μg/mg Cr.

Result(s): Long luteal phases begin with long luteinization processes. The early luteal phase is marked by low PDG and high LH levels. Long luteinization phases were correlated with low E1G and low PDG levels at day 3. The length of the early luteal phase is highly variable between cycles of the same woman. The duration and hormonal levels during the rest of the luteal phase were less correlated with other characteristics of the cycle.

Conclusion(s): The study showed the presence of a prolonged pituitary activity during the luteinization process, which seems to be modulated by an interaction between P and LH. This supports a luteal phase model with three distinct processes: the first is a modulated luteinization process, whereas the second and the third are relatively less modulated processes of progestation and luteolysis.

Ecochard R, Bouchard T, Leiva R, Abdulla S, Dupuis O, Duterque O, et al. Characterization of hormonal profiles
during the luteal phase in regularly menstruating women. Fertility and Sterility 2017;108:175-
182.e1. https://doi.org/10.1016/j.fertnstert.2017.05.012.

Background: Serum progesterone (P) rises after ovulation in the luteinisation process.

Objective: To identify an accurate progesterone threshold to confirm ovulation in the assessment of a woman’s fertility.

Methods: In a secondary analysis of an observational European multicentre study, this study included 107 women over 326 menstrual cycles and tracked daily first morning urine (FMU), changes in observed cervical mucus discharge, serum progesterone, and ultrasonography to identify the day of ovulation. A serum progesterone level was available for 102 women over a total 260 cycles with one or two P levels per cycle.

Results: It was found that a single serum P⩾5ng/ml is highly specific with a specificity of 98.4 (95% CI 96.0-99.5), with a sensitivity of 89.6 (95% CI 85.2-92.9).

Conclusion: A random serum progesterone level ⩾5ng/ml confirms ovulation. This may be of use for clinicians wanting to confirm that ovulation has occurred.

Leiva R, Bouchard T, Boehringer H, Abulla S, Ecochard R. Random serum progesterone threshold to confirm
ovulation. Steroids 2015;101:125–9. https://doi.org/10.1016/j.steroids.2015.06.013.

Objective: To describe FSH profile variants.

Design: Observational study.

Setting: Multicenter collaborative study.

Patient(s): A total of 107 women.

Intervention(s): Women collected daily first morning urine and underwent serial ovarian ultrasound.

Main outcome measure(s) fsh result(s): The individual FSH cyclic profiles demonstrated a significant departure from the currently accepted model. A decline in FSH levels at the end of the follicular phase was observed in only 42% of cycles. The absence of this decline was significantly associated with a shorter luteal phase and higher pregnanediol-3α-glucuronide, FSH, and LH levels at the time of ovulation. In 34% of the cycles, significant FSH variability was observed throughout the follicular phase; this variability was associated with higher body mass index and lower overall FSH and LH levels throughout the cycle. The FSH peak occurs on average 2 hours before ovulation. The FSH peak duration was shorter than the LH peak.

Conclusion(s): These results suggest that average FSH profiles may not reflect the more complex dynamics of daily hormonal variations in the menstrual cycle. It is possible that discrepancies between the average normal FSH profile and the individual day-to-day variants can be used to detect abnormalities.

Ecochard R, Guillerm A, Leiva R, Bouchard T, Direito A, Boehringer H. Characterization of follicle stimulating
hormone profiles in normal ovulating women. Fertil Steril 2014;102:237-
243.e5. https://doi.org/10.1016/j.fertnstert.2014.03.034.

Objective: To describe the LH surge variants in ovulating women and analyze their relationship with the day of ovulation and other hormone levels.

Design: Secondary analysis of a prospective cohort observational study.

Setting: Eight natural family planning clinics.

Subjects: Normally fertile women (n ¼ 107) over 283 cycles.

Intervention(s): Women collected daily first morning urine, charted basal body temperature and cervical mucus discharge, and underwent serial ovarian ultrasound.

Main Outcome Measure(s): Urinary LH, FSH, estrone-3-glucuronide (E3G), pregnanediol-3a-glucuronide (PDG), and day of ovulation by ultrasound (US-DO).

Result(s): Individual LH surges were extremely variable in configuration, amplitude, and duration. The study also showed that LH surges marked by several peaks were associated with statistically significant smaller follicle sizes before rupture and lower LH level on the day of ovulation. LH surges lasting >3 days after ovulation were associated with a lower E3G before ovulation, a smaller corpus luteum 2 days after ovulation, and a lower PDG value during the first 4 days after ovulation.

Conclusion(s): In clinical practice, LH profiles should be compared with the range of profiles observed in normally fertile cycles, not with the mean profile. (Fertil Steril
2013;99:279–85. 2013 by American Society for Reproductive Medicine.) 

Direito A, Bailly S, Mariani A, Ecochard R. Relationships between the luteinizing hormone surge and other
characteristics of the menstrual cycle in normally ovulating women. Fertility and Sterility
2013;99:279–85. https://doi.org/10.1016/j.fertnstert.2012.08.047.

We are learning the importance of living in harmony with nature’s rhythms rather than attempting to control them. NFP is an example of this intention.

Reflections on the Spirituality of Natural Family Planning (1994):
Richard Fehring, Marquette University

I shall in this essay undertake such an inquiry and argue that the use of contraception promotes dispositions that are contrary to those necessary for respect for life and therefore required for what Pope John Paul II has called a “culture of life.” Consequently, the pope has been right to say that pro- Life and Learning VII life strategy must, in fact, include teaching the unacceptability of contraception (EV #13, 97; cf. 88).

My argument will be presented in four parts. The first will assess a proposal that contraception is itself contralife. I shall show that this argument is inadequate. A more adequate argument will require an analysis of the manner in which marital intercourse serves human goodness, since contraception affects the act of intercourse, and not merely accidentally. I shall allow John Paul’s writings, especially some of his pre-papal philosophical work, to guide this analysis, not as an appeal to authority, but because one finds in them a detailed and especially insightful account of the issue, and because he has shown a concern about contraception that is a manifestation of this insight.

Thus the second part of this essay will present some features of John Paul’s philosophical anthropology and the starting point of his corresponding personalistic ethics.

The third will use this ethics to evaluate marital love, intercourse, and contraception. In these parts I shall explain that marital intercourse modified by contraception is immoral for the reason that it objectively embodies a disposition toward one’s spouse that treats this person as an object of use rather than love, and therefore not as a person.

In light of this evaluation of contraception, the fourth part will return to the question of whether the dispositions embodied and therefore promoted by contraception are compatible with respect for life. Here I shall argue, again following the pope, that it is precisely use of persons, as opposed to love for them, that is most fully manifest in disrespect for life. It follows that, while the disposition toward one’s spouse objectively embodied by contraception is specifically different from the disrespect for life embodied by abortion, the two dispositions are nevertheless related—both are species of a general disposition toward use rather than love of persons. Acceptance and reinforcement of this disposition, as by contraception, leads ultimately to the deaths of those who are most vulnerable, especially the unborn. I shall suggest some implications for pro-life efforts.

The Incompatibility of Contraception with Respect for Life (1997):
Kevin E. Miller, Franciscan University

Almost twenty years ago, Pope John Paul II in his apostolic exhortation Familiaris Consortio called on scholars to study the anthropological and moral differences between the recourse to the natural rhythms of a woman’s menstrual cycle (i.e., natural family planning) and contraception (1).

Although natural family planning (NFP) and contraception can both be used to prevent pregnancy, there are conspicuous differences between use of natural methods and contraception. Most people, however, have difficulty in distinguishing what the differences are and in understanding why some religious groups, health professionals, and other members of society consider contraception (but not natural family planning) immoral or problematic. As the title indicates, our focus will be more on anthropological than on moral differences. That is, we do not explicitly address the question, “What is the core criterion for judging the moral rightness or wrongness of contraception?”

Nevertheless, our findings on the consequences of contraception and sterilization are quite relevant for moral judgments, even for those who use a consequentialist or proportionalist approach in morals. For example, how moral is it to treat a woman’s fertility/reproductive system as a disease or to alter or destroy it?

Discussing anthropological differences between contraception and natural family planning raises questions not usually asked in comparing what can at first sight simply appear to be two approaches toward the same end (birth control). These questions invite a recontextualization of the entire discussion within much more inclusive concerns for the complete human person, male and female, and theirsexual relationship to each other (1). In most areas of personal health, many individualsrightly call for medicinal or surgical approaches to health care that are more holistic and natural and less intrusive, and they also actively support ecological conservation of the world’s macro-environment. Yet, there seems to be a puzzling inconsistency when it comes to the very delicate micro-environment, and especially that of the female reproductive system and its care. Respect for the natural environment and preference for fostering natural biological processes in health care (rather than premature or even unnecessary medical or surgical interventions) would be expected to favor natural ways of dealing with human fertility. They would seem to preclude support for the medical, mechanical, or surgical intrusiveness of contraception or sterilization over the natural processes of NFP or fertility awareness.

The almost universal promotion of contraception rather than of fertility awareness is a puzzling anomaly in view of the use of holistic and ecological principlesin other health and environmental concerns. An even more inclusive context for interpreting arguments about contraception, especially the arguments in the highly controversial encyclical Humanae Vitae of Pope Paul VI, would place the papal arguments about contraception in the context of the Church’s social teachings and her teachings on the authentic development of peoples(for example, in the encyclical Populorum Progressio) (2). But space limits us to the more personal and interpersonal rather than the more general social context.

This paper will analyze the two approaches to family planning in order to extrapolate and clarify the differences. Most of its evidence is empirical (supplied chiefly by Nursing Professor Richard Fehring), but it will also include some reflection on the evidence from a faith perspective (with the help of theologian Fr. William Kurz). The first part of the paper will define, compare, and contrast NFP and contraception and will examine some consequences of the use of each. In the second part, research evidence will be presented that compares NFP to contraception on a number of psychological and social variables. The paper ends with a table that summarizes the differences.

Anthropological Differences between Contraception and Natural Family Planning (2002):
Richard Fehring Marquette University,
William Kurz Marquette University

This paper will contend that it is the primeval human temptation “to be as God” that lays the ultimate foundations within the overall biblical perspective and worldview for the links between abortion and contraception, even though neither abortion nor contraception receives significant explicit discussion in Scripture.

A brief overview of the rise of Christian acceptance, first of contraception, consequently of abortion, can help to contextualize these issues. It can provide some recent perspective on how contraception and abortion relate to each other and to this enticement in Genesis “to be as God.”

Scriptural Links between Abortion and Natural Family Planning (2003): William Kurz, SJ – Marquette University

Over 30 years ago the founders of the Christian Family Movement (CFM), a worldwide Catholic family action group, conducted a survey to investigate the marital effects of practicing “rhythm.”

Their final report indicated that many participants felt that periodic abstinence was harmful to their marriage and caused spiritual and religious distress.

The CFM survey results were thought to have been influential in convincing the 1966 Papal Birth Control Commission to recommend a change in church teaching. The purpose of this paper is to report a re-analysis of the 1966 archived data (in the light of the Papal Encyclical Humane Vitae–On the Regulation of Birth) and to compare that study with responses from married couples using modern methods of NFP, i.e., methods that purport to be more effective and to have fewer days of periodic abstinence.

This paper will provide an examination of the original study within its historical context and report on the responses relating to spirituality from the 1966 couples in comparison with couples currently practicing periodic abstinence through the Billings Ovulation Method.

Spiritual Responses to the Regulation of Birth (A Historical Comparison) (2003): Richard J. Fehring, and Elizabeth (McGraw) Sutton
Marquette University

Luc Bovens’s assumption that intercourse on the fringes of the fertile phase of the menstrual cycle by users of rhythm will result in increased embryo loss is not based on convincing evidence (J Med Ethics, 2006;32:355-356).

In fact, some scientific evidence points to the opposite conclusion. Researchers at the US National Institutes of Health Science reported they found no evidence for this association based on single acts of intercourse during the fertile window.(1)

In a subsequent study they did find a significant increase in pregnancy loss from acts of intercourse on the estimated day of ovulation, but the study had severe limitations due to imprecise timing of intercourse and in estimating what acts of intercourse actually caused the pregnancy.(2)

But neither of these studies involved couples using rhythm or what is commonly known as natural family planning (NFP).

Rhythm Method as Cause of Embryonic Death Based on Flawed Assumptions (2006):
Richard Fehring

This paper is based on an answer to a question from Theresa Notare, Ph.D., director of the Natural Family Planning Program of the United States Conference of Catholic Bishops (USCCB).

She asked me and Kathleen Raviele, M.D., the president of the Catholic Medical Association at that time, what Catholic scientists and physicians can do to promote natural family planning and what could the Catholic Church in the United States do to help physicians and health professionals promote NFP.

This paper is essentially my answer to Dr. Notare, but instead of just listing some of my ideas, I framed the answer in the context provided by former Popes, and especially John Paul II and his call to help build a culture of life in his encyclical Evangelium Vitae.

This paper reviews the Church’s historical call to health professionals to study and teach natural family planning methods, briefly analyzes the current state of NFP in Catholic health care, and provides an answer to Dr. Notare from the perspectives of research, education, and practice.

The Catholic Physician and Natural Family Planning: Helping to Build a Culture of Life (2009):
Richard Fehring
Marquette University

This paper provides a counter-argument to the notion that breastfeeding acts as an abortifacient and is thus the moral equivalent of abortion-causing drugs, e.g., Plan B or what is referred to as emergency contraception.

Those who make this comparison do so in order to ridicule health professionals who refuse to prescribe or refer abortifacient-type contraceptive drugs and to ridicule laws that protect this right of conscience for healthcare professionals.

In this paper I will provide evidence that breastfeeding does not induce early pregnancy loss and that it is not the moral equivalent to the administration of abortifacient-type drugs.

Is Breastfeeding the Moral Equivalent of Emergency Contraception in Inducing Early Pregnancy Loss? (2010):
Life and Learning
Richard J. Fehring, Marquette University

The purpose of this paper is to illustrate and discuss three case scenarios of women (and their spouses) who are experiencing difficult life situations in which they might choose to have an abortion if they would have an unintended pregnancy.

For these situations the current medical profession often recommends sterilization, for either the woman or her spouse, so as to prevent an unintended pregnancy.

The three cases involve: (1) a woman with breast cancer and on a medication that would result in a deformed child, (2) a woman with five children under the age of five who is currently breastfeeding an infant, and (3) a peri-menopausal woman who has a health problem and who has a significant risk for having a child with Down’s syndrome.

The use of modern natural family planning (NFP) methods and special protocols developed by researchers at Marquette University to manage these special problems will be presented. An argument will also be made that the use of NFP is more healthy and beneficial for the woman, her potential child, her spouse, and family. Conversely, use of hormonal contraception is either medically contra-indicated in these situations or unnecessary.

Preventing Unintended Pregnancies (the Natural Way) among Women with Hard Cases (2013):
Richard Fehring, Marquette University

Hispanics are the largest minority group in the U.S. and they contribute to over 50 percent of Catholics under the age of 25. The purpose of this study was to determine the patterns of contraceptive use (current and ever), natural family planning (NFP), and abortion among U.S. Hispanic women between the ages of 15 and 44 years and to compare their patterns of use to non-Hispanic women of the same age range. A particular interest was to determine the influence of faith on the choice of family-planning methods among the sexually active U.S. Catholic Hispanic women. Data for this study came from the National Survey of Family Growth 2006–2008, which included 1,613 Hispanic and 5,743 non-Hispanic women between the ages of 15 and 44. Approximately 57 percent of the Hispanic women are Catholic.

In general, U.S. Hispanic women had significantly less frequent use of the hormonal pill, male condom, withdrawal, and vasectomy (of male partner) but more frequent use of the IUD and Depo-Provera compared to non-Hispanic women. There was little use of NFP and no difference in the frequency of reported abortion. Catholic Hispanic women had significantly less frequent use of the male condom, the Pill, vasectomy, and abortion and more use of NFP compared to non-Catholic Hispanic women. Although there is some positive influence of faith among the sexually active Hispanic women of reproductive age, overall, the amount of ever use of sterilization (21 percent), condom use (80 percent), Pill use (66 percent), and Depo-Provera (30 percent) is remarkable. The more frequent use of Depo-Provera and the IUD might reflect the economic level of the participants and the use of federally funded family-planning services. Hispanics are the largest and the fastest growing minority population in the United States.1 According to the Pew Research Center approximately one-third of all Catholics in the U.S. are Hispanic, and they project that this proportion will continue to grow for decades to come.

Furthermore, according to the United States Conference of Catholic Bishops, currently, 50 percent of U.S. Catholics under the age of 25 are Hispanic.3 Since many Hispanics follow the Catholic faith, which only allows the use of natural family planning (NFP) for avoiding pregnancy, it would be interesting to know the family-planning patterns of Hispanics in the U.S. and to see how they differ from the U.S. population in general. The purpose of this report is to provide an analysis of the familyplanning practices (i.e., common contraceptives, abortion, and natural family planning) among U.S. Hispanic women in comparison to all other U.S. women of reproductive age. Of particular interest is the use of contraception, NFP, and abortion among U.S. Hispanic Catholic women, that is, to determine the influence of faith on family-planning patterns. Before analyzing the current family-planning patterns of U.S. Hispanics, a brief overview of family planning among Hispanics as found in the literature is presented.

Family Planning, Natural Family Planning, and Abortion Use among U.S. Hispanic Women (2012):
Dana Rodriguez Marquette University,
Richard Fehring Marquette University

Abstract: The purpose of this study was to determine the influence of contraception, abortion, and natural family planning (NFP) on divorce rates of US women of reproductive age. The variables of importance of religion and frequency of church attendance were also included in the analysis. The study involved 5,530 reproductive age women in the (2006–2010) National Survey of Family Growth who indicate that they were ever married. Among the women who ever used NFP only 9.6 percent were currently divorced compared with the 14.4 percent who were currently divorced among the women who never used NFP (x2 = 5.34, P < 0.21). Odds ratio analysis indicated that ever having an abortion, sterilization, and/or methods of contraception increased the likelihood of divorce – up to two times. Frequency of church attendance decreased the risk of divorce. Although there is less divorce among NFP users the reason might be due to their religiosity.

Lay summary: Providers of natural family planning (NFP) frequently mention that couples who practice NFP have fewer divorces compared to couples who use contraception. Evidence for this comment is weak. This study utilized a large data set of 5,530 reproductive age women to determine the influence that contraception, sterilization, abortion, and NFP has on divorce rates. Among the women participants who ever used NFP only 9.6 percent were currently divorced compared with the 14.4 percent who used methods of contraception, sterilization or abortion as a family planning method. Frequency of church attendance also reduced the likelihood of divorce.

The Influence of Contraception, Abortion, and Natural Family Planning on Divorce Rates as Found in the
2006–2010 National Survey of Family Growth (2014):
UFL Life and Learning Conference XXIV
Richard Jerome Fehring Marquette University

This paper is an historical analysis of the issues of contraception and abortion as presented through the focus and lens of articles in The Linacre Quarterly, the official journal of the Catholic Medical Association (CMA). The twenty-year history includes the ten years before and after the pivotal papal encyclical Humanae vitae (HV). The articles show the clear link between the issues of contraception and abortion and how these issues led to the decline of the Federation of the Catholic Physician Guilds (the precursor of the CMA in the United States). It was a decline that, I propose, lessened opposition to liberalized abortion laws. There is, however, a new and revised CMA that has been built on a faithful and prolife membership of physicians and other health professionals.

A Twenty-Year History (1958-1978) of Contraception and Abortion as Experienced by the Catholic Medical
Association (2018):
Richard J. Fehring
UFL Life and Learning Conference XXIX (2018)

Hormonal and other types of contraceptive methods are often prescribed to adolescents and young adults for the treatment of health problems and to avoid unwanted pregnancies. We hypothesized that there is a greater likelihood of pregnancy, abortion, sexually transmitted diseases (STDs), and sexual behaviors that enhance such problems (e.g., earlier sexual debut and multiple sex partners) for single adolescents and young adults currently using contraception than for adolescents and young adults not using contraception. To test this hypothesis, we used data from 1,365 adolescents and young adults in the 2011-2013 National Survey of Family Growth to describe the influence of current use of contraception on sexual debut, multiple sex partners, sexually transmitted diseases, pregnancy, and abortion. We found that current use of contraception by adolescents and young adults in the U.S. results in a greater likelihood of pregnancy, abortion, and sexually transmitted diseases compared with the rates for those adolescents and young adults who never used oral contraceptives. Furthermore, those adolescents who currently use oral contraceptives had significantly more male sexual partners than those who never used them and an earlier sexual debut by almost five years. We concluded that the use of oral contraceptives by adolescents and young adults facilitates higher risk sexual behaviors. Further research is recommended to confirm these associations.

Influence of Current Contraceptive Use on the Abortion and Sexually Transmitted Disease Rates among
Adolescents and Young Adults in the United States (2018):
Richard J. Fehring, Ph.D., R.N.
Thomas Bouchard, M.D.
and Maria Meyers, M.D.
UFL Life and Learning Conference XXVII

This paper considers the implications of Pope Saint John Paul II’s encyclical Evangelium vitae (The Gospel of Life) for the use, teaching, and research of natural family planning (NFP). In this encyclical the pope analyzed the connections between use of contraception and abortion, encouraged the development ofNFP centers, advised that NFP be provided to all married couples, urged health care professionals to be involved in teachingNFP, and recommended that universities be involved with research in NFP, especially to explicate NFP’s effectiveness. This paper provides evidence for the association of contraception with abortion, for the state of NFP among married couples in the United States, and gives examples of NFP centers that focus on women’s health. This paper also presents evidence for the effectiveness of NFP in helping couples to avoid and achieve pregnancy. In light of the pope’s call for universities to be involved with building a culture of life, this paper explains the Marquette University Institute for NFP as doing so through educating health care professionals in how to teach the Marquette Model system of NFP, by conducting NFP research, and by offering innovative NFP services. The paper ends echoing John Paul II’s call for women to be leaders in developing a culture of life by discussing ways health care professional women have promoted NFP through social media, the internet, innovative technology, and women’s health services.

Evangelium vitae and Promoting a Culture of Life through Natural Family Planning (2020):
Life and Learning (2020)
Richard J. Fehring