The Particular Witness of a Catholic Obstetrician and Gynaecologist: A Sign of Contradiction in the Culture of Death

 

THE FUTURE OF OBSTETRICS AND GYNAECOLOGY: The Fundamental Right To Practice and be Trained According to Conscience: An International Meeting of Catholic Obstetricians and Gynaecologist

Organised by the World Federation of Catholic Medical Associations (FIAMC) and by MaterCare International (MCI)
Sponsored by the Pontifical Council for the Health Pastoral Care ROME, June 17th-20th, 2001

Reproduced with permission

1. A More Constructive Approach to Obstetrics and Gynaecology

But there is another side to this question. In a culture of death many women are frustrated by the over-medicalisation of O&G practice, by the presumption of contraception, of genetic counselling and prenatal diagnosis for the purpose of selective abortion and of IVF for infertility, and by the lack of research into and provision of less interventionist approaches to managing women's health.

In this paper I address some particular areas of O&G practice in which in being informed by a Catholic perspective on respect for human dignity in sexual and reproductive health, we are led to seek out better solutions to problems affecting women's health. That is to say, a Catholic O&G develops better, less interventionist, more woman and child friendly solutions and these constitute a more constructive approach to O&G practice.

2. Genetic Counseling

There is a need for O&G specialists who are prepared to support a woman and her baby throughout pregnancy and not put either of them at risk with intrusive tests that yield no beneficial information for obstetric care, but are aimed only at selective abortion. There is a great need for genetic counseling and genetic screening which is sensitive to respect for the dignity and the life of both mother and child.

The human genome project is yielding information at a great rate, but so far it has yielded no therapies. If one were to divide the talk about gene therapy by the gene therapies actually achieved the answer would be infinity. What the human genome project has yielded is a growth in genetic screening and genetic diagnosis.

The net outcome is much greater scope for unjust discrimination in insurance, employment and by financial institutions, and the most severe discrimination of all, reproductive discrimination, in which couples are counseled against having their own children, or advised to use prenatal diagnosis and selective abortion, or IVF and testing and genetic selection of embryos, or more recently, the prospect of somatic cell nuclear transfer from the unaffected parent or a relative to form an embryo asexually.

Women often feel relatively powerless in the face of the medical desire to prevent the birth of children with abnormalities. A significant follow-up study of 84 women, in West Scotland, who had had second trimester terminations of pregnancy for foetal abnormality17 concluded that within the context of continuing medical care, professionals have a responsibility to learn about this new kind of grief and to recognise (keeping the couples' reticence in mind) the signs that may signal a need for professional mental health intervention."17

An Oxford study of 71 women who had had termination of pregnancy for foetal abnormality18 found that in the month after termination of pregnancy, many had high levels of psychiatric morbidity (41%) as determined by a standardised psychiatric interview, which is 4-5 times higher than in non-puerperal (10%) and post-partum women (9%) in the general population. 31% still felt guilty and angry 13 months later. Of the 71 women, about a third saw the baby after the termination, and of those who did not, just under a third had wished that they had. 14% arranged funerals for their babies.

With the concentration on so-called "prevention" by interventionist ways, there is a danger that the research effort will go into diagnostic and screening technologies, rather than into developing therapies. There is now an urgency for us to encourage the development of treatments for genetic diseases so that the economic and social pressure to screen and eliminate those with genetic abnormalities can be reduced.

We should support gene therapies which are predicated on the use of a patient's own cells, or more conventional pharmaceutical approaches to genetic illness. There is a grave danger that a new branch of medicine will develop that is based upon the laboratory generation of human embryos using asexual reproductive techniques such as somatic cell nuclear transfer.

Now is the time for us to emphasize that the use of a patient's own tissues as a source of stem cells that can be cultured to develop therapies is well-established. In fact the technology for culturing adult stem cells is at least forty years old. We need to identify the advantages of histo-compatibility of a patient's own cells and the fact that using embryos as a source would be immensely complicated by the problems of creating a demand for eggs from female relatives of the patient (so far in animals hundreds of eggs are needed to produce a viable embryo from which ES cells might harvested). A major problem with somatic cell nuclear transfer is that it produces such high rates of abnormality. Cloned embryos are not a safe source of embryonic stem cells. We must also firmly reject the notion that it is acceptable to produce a class of laboratory manufactured human embryos, who, because they are reproduced asexually, have no parents, no-one with an interest in their fate, and they simply become exploitable.

It is of great importance that catholic health care institutions foster research into genetic disease aimed at treating the disease and that we establish genetic counselling services which aim to help an anxious woman and her partner by giving them accurate information about the disease that they may transmit to their child, and about the sources of assistance that are available to help them cope, including the medical treatments available. We need to show that there is another way, a constructive way of coping with genetic disease. In particular we need to make it clear that every child is welcome, not just the genetically normal or perfect, and that genetic variation is one of the blest aspects of humanity.

From a philosophical and theological point of view, right-minded people need to take the secular claim made in the UN Universal Declaration on the Human Genome and Human Rights, that the human genome is the source of unity and underlies the inherent human dignity and the equal and inalienable rights of all members of the human family, and give that claim real practical strength by opposing genetic discrimination in all its manifestations and instead expressing our welcome for all and our willingness to put effort into therapies that relieve genetic disease that would otherwise limit the lives of those who have a genetic abnormality.

3. Fertility Awareness

An obvious area where a constructive approach is needed in gynaecology is that of the natural management of fertility and infertility. By encouraging women to learn to interpret their symptoms of infertility, possible fertility and the day of maximum fertility and the time of ovulation, they can be assisted to gain control over their fertility without medical intervention, to gain earlier indications of reproductive tract pathology, and to overcome infertility by locating when they are possibly fertile more precisely. In a culture of death and willing medical and surgical intervention, women are not likely to be encouraged to develop these skills.

This is a particular issue for MaterCare International. Natural fertility regulation is cost free. It is knowledge only. In providing services to developing countries unable to afford expensive western pharmaceutics, natural fertility regulation provides a viable alternative. It is far more effective than the usual option of IUDs or barrier methods.

I want to stress here the importance of comparing methods of family planning by using only those studies that are independent, adequately constructed from a sampling perspective, and undertaken in initiates. Any method of family planning will show high effectiveness if it is undertaken on those who have persisted with the method: those who are likely to become pregnant will do so in the initial phase and hence will be excluded from the sample. There have been three independent, well-constructed studies of the Billings Ovulation Method and its use by initiates. Table two summarizes the results of those trials.

Table Two. Independent Studies of the Effectiveness of the Billings Ovulation Method Used by Initiates to Avoid Pregnancy

a) World Health Organisation (1977-1981) Multi-centre - Auckland, Dublin, San Miguel, Bangalore and Manila Publication: World Health Organisation "A prospective multicentre trial of the ovulation method of natural family planning" Fertility and Sterility 1981 Vol 36, p. 152ff; 1981 Vol 36, p.591ff. 869 women 10, 215 cycles of use 2.2 Method related pregnancies per hundred women years in initiates

(b) Indian Council of Medical Research Task Force on NFP (1995) States of Uttar Pradesh, Bihar, Rajasthan, Karnataka and Pondicherry Publication: I. Bhargava et al "Field Trial of Billings Ovulation Method of Natural Family Planning" Contraception 1996, Vol 53 pp. 69-74 2,059 women 32,957 woman months of use 0.86 Method related pregnancies per hundred women years in initiates

(c) Jiangsu Family Health Institute, China (1997) Publication in English Translation: Shao Zhen QIAN, De-Wei ZHANG "Evaluation of the effectiveness of a natural fertility regulation program in China" Bulletin of the Ovulation Method Research and Reference Centre Vol 24, No. 4 pp 17-22, 2000 1,235 women 14,280 women months of use No method related pregnancies in initiates (5 user-related pregnancies)

The data would indicate that the evidence-based method-related Pearl Index for BOM is 0-2.2 p/hwy in initiates. This is at least comparable to the oral contraceptive and certainly better then even the best figures given for barrier methods.

It will be the case wherever MaterCare operates that there will be pressure on the teams to do sterilisation and even abortion. In countries that are suffering poverty or war, the solution seems so often to be to advocate the provision of sterilisation and abortion as a priority.

The obvious solution to this is for MaterCare agencies to be allied to natural family planning centres. There is a very effective model that has been developed in China. I am most familiar with the World Organisation for the Ovulation Method (Billings) in this respect. WOOMB has gained a very firm foothold in many developing countries but particularly in China. The Billings have made twenty-two trips to China taking with them a team of reproductive health educators and working with the Government run family planning service centres. In each place they visit they train local doctors and other health professionals, including obstetricians and gynaecologists, and establish a centre with the capacity to train teachers. Since 1995, at least 400 gynaecologists in China have completed the formal 5-day training and teacher accreditation program conducted by WOOMB.

The earliest of the centres in China to have been assisted by WOOMB is the health institute in Nanjing province which reports the following:

Table 3 Nanjing Centre

l 1995-2001
l 48 teacher training courses
l 2250 trained teachers
l 210 lectures to medical practitioners (mostly women gynaecologists)
l 27,700 couples

4. Rape Crisis

In my country, Australia, there are many Catholic Hospitals, including many Catholic obstetric hospitals and many Catholic hospitals offering emergency care. But there is no Catholic hospital offering care for women who have been raped. There are no Catholic rape crisis centres. I would expect that that is probably not a situation that is unique to Australia. The fact of the matter is that Catholic hospitals, knowing that they cannot offer abortion or use abortifacients, have more or less surrendered this area of care to the culture of death.

Yet of, all people, a woman who has been raped is most in need of care and support. This is an issue that MaterCare cannot avoid. So often rape accompanies war, particularly warfare based on ethnic, racial or religious differences. It seems that killing the men but degrading the women and even a desire to make them pregnant to the conquerors is a particularly vicious aspect of ethnic warfare. If MaterCare is sending in teams to places torn by such conflicts, then the organisation needs to address the development of satisfactory protocols for the care of women (including those who are still children) who have been raped.

Women who have been raped are often subjected to the further trauma of procedures and treatments aimed at preventing or eliminating the possibility of a child eventuating. Since a woman is infertile most of the cycle, there is an issue whether most use of the morning after pill is in fact unnecessary.

5. The Morning After Pill

(a) A Common Problem

In general practice it has become very common for women, especially young women, to seek medical assistance the morning after experiencing a broken or slipped condom or natural "unprotected" sexual intercourse. Condoms are presented as the universal safety precaution. But even with perfect use to avoid pregnancy there is a variety of studies putting the Pearl Index for pregnancy for condoms between 3 and 15 per hundred women years1.

Studies on perfect condom use are usually done on adults, there being ethical difficulties with undertaking such a study on teenagers. Consequently, it is much more difficult to obtain condom effectiveness figures for teenagers. Teenagers lack experience, may be more likely to be experimenting, and, often enough, change partners relatively frequently. One would expect condom efficacy in relation to pregnancy and disease to be different in teenagers.

In a major study2on condom use by 200 sexually active girls between the ages of 14-21, median 17 years, Christ et al found that a very high proportion reported problems with condoms in the past year, 31% had experienced a condom breaking, 39.5% had experienced a condom falling off, and 6% had become pregnant with a condom. 85% reported negative experiences. Avoiding pregnancy and disease are justifiably a major source of worry for sexually active adolescents, and condoms do not alleviate that worry. Their experience with condoms often does not tally with the assurances that educators often give that condomised sex is safe. In general practice, girls often present distressed, requesting assistance after natural intercourse or after a condom problem has occurred.

(b) The "Morning After Pill"

The MAP is usually given as a double dose of one of the higher dose combined pills taken twelve hours apart, the so-called Yupze regimen. It normally causes a shedding of the endometrium resulting in loss of the embryo if fertilisation occurs in that cycle. The MAP may also suppress or delay ovulation. This latter contraceptive effect would, of course, be ineffective in preventing fertilisation, if ovulation was occurring or had already occurred at the time. In that case, the MAP's effect would be on nidation.14-15-16

It is unlikely that the MAP would cause changes to the cervical mucus sufficient to completely prevent sperm from reaching the fallopian tube. Even the normal natural rise in progesterone, which begins eight hours before ovulation, does not prevent residual channeling in the cervix which is capable of allowing the passage of sperm on the third day after the peak day of mucus.3

Since a woman is infertile most of the cycle, there is an issue whether most use of the MAP is in fact ineffectual and hence pointless. The MAP is not without significant medical side effects. It is certainly not recommended as a routine way of controlling fertility.

If it were possible to identify that: (a) an act of intercourse in the previous twenty four hours could not have resulted in fertilization, (b) ovulation and hence possible fertilization might yet occur in the near future unless there is intervention, or (c) ovulation had already occurred and the ovum already likely to have been exposed to sperm, and that fertilization, if it was to occur had already occurred, then this would seem to be useful information to determine whether any intervention were necessary and to allow the woman to make an informed choice.

c) Identifying Fertile and Infertile Phases

The search for reliable methods of natural family planning has resulted in the capacity to identify the infertile and the possibly fertile phases of the cycle and ovulation. A woman's own observation of the presence of mucus at the vulva and the sensation produced, allows her to recognise when she is infertile, when possibly fertile and the occurrence of ovulation.

The phases of the cycle are also identifiable by testing for urine oestrone glucuronide and urine pregnanediol glucuronide using the Brown monitor5.

Serum testing of oestradiol and progesterone also can be used to confirm the phases of a woman's cycle.

Macroscopic analysis on internal examination can identify whether cervical mucus is present and whether it is of a consistency that indicates possible fertility. Low power microscopic analysis of the cervical mucus would confirm the mucus type6, but obtaining the sample (in a procedure similar to obtaining a sample for a Pap-smear test) does require experience.

Finally, ultrasound can be used to identify ovulation.

Working independently,

… Professor James Brown7, charting the ovarian hormonal levels and correlating them with the women's charting of when intercourse occurred in relation to pregnancy occurring, established the relation between the ovarian and pituitary hormones and the different phases of the cycle;

… Professor Eric Odeblad8 undertook bio-physical assays of cervical mucus and identified the roles of the different types of cervical mucus in fertility and infertility.

… The Drs. Billings9 studied women's observations of their symptoms and correlating those charted observations of the mucus symptom with whether pregnancy resulted from sexual intercourse during the different phases of mucus symptom. They devised a set of rules to avoid or achieve pregnancy on that empirical basis. According to the standards of evidence-based medicine the Billings rules to avoid pregnancy have a method related Pearl Index of 0-2.2 pregnancies per hundred women years in initiates10.

When these three areas of research were combined they were mutually reaffirming and each complemented the other in developing a full understanding of the relationship between the cervix, follicular development and ovulation. Between them, the Billings, Brown and Odeblad have reviewed hundreds of thousands of women's cycles.

It is possible to offer to women who are in distress over an event that happened during the previous twenty-four hours and which they fear may result in pregnancy, the possibility of identifying whether they are in fact infertile or alternatively whether they may conceive or may already have conceived.

Figure One, which was developed with assistance from Professor Brown, Dr John Billings and Dr Evelyn Billings, describes the woman's cervical mucus symptoms and what might be found if an internal examination were to be done. An examination is often done for forensic purposes after rape. If a woman had been charting her symptoms it would be unnecessary to undertake further examination or testing, but she might want further confirmation or, as is the norm unfortunately, she may be ignorant of her symptoms and how to interpret them.

Figure One also shows serum oestradiol and progesterone levels for each phase. Pathologists usually offer a service, including an after hours service, for serum oestradiol and progesterone testing. If marked "urgent", the result can be available in several hours.

Also shown on Figure One are the urine oestrone glucuronide and pregnanediol glucuronide ranges for the different phases of the cycle. If the woman, according to these indicators, falls into the areas of the pre-ovulatory infertile phase or the luteal infertile phase then she can be reassured that pregnancy is most unlikely from an event occurring during the previous 24 hrs. It would be possible, if thought necessary, to add an ultrasound examination of the ovaries to gain further confirmation of the stage or absence of follicular development and whether or not ovulation was about to or had occurred recently, but either serum or urinary results would be sufficient.

From Figure One, it is evident that a woman who has a serum oestradiol < 440pmol/L and serum progesterone <4.9nmol/L, or a serum progesterone > 12 nmol/L, is in an infertile phase of her cycle. These figures are conservative erring on the side of caution. There is a grey area when the progesterone is between 7 and 12 nmol/L which further research may narrow.

The symptoms of a woman who was charting would indicate whether she had ovulated. This information would more precisely identify the possibly fertile period. A woman who was charting adequately would not need confirmatory serum or urine testing. Though not trained to chart, a woman may nevertheless be able to provide some details of her cycle during the history-taking. The doctor may rely on the latter in conjunction with his or her examination and the blood or urine tests. A second blood or urine test taken a day later would also more precisely define in which direction the trend in the serum or urine values was and thus provides a basis for a more precise assessment.

Further it should also be confirmed with the woman that there were not earlier incidents by which she may have conceived. A pregnancy test confirming pregnancy would contra-indicate MAP intervention.

A WHO study on identifying fertility by the mucus symptom showed that the probability of pregnancy in relation to the Peak Day (determined by the mucus symptom alone) was 0.67 if intercourse occurred on Peak Day, 0.5 on PD - 1 day, 0.5 on PD - 3 to -1 days if there is slippery mucus, and 0.5 if there is only sticky mucus, 0.4 on PD + 1, 0.2 on PD +2, and 0.1 on PD +3. Outside the fertile period (commencement of mucus change to PD + 3) the probability of pregnancy was 0.004.11 The latter figure is especially significant for these purposes.

In the circumstance of rape, one would expect that it would be particularly reassuring for a woman, who is in either of the infertile phases, to be told that her cervix is closed with a G-mucus plug and that her vagina is naturally hostile to sperm. The information would also be reassuring for women who had simply had an unplanned exposure to the risk of pregnancy.

With this knowledge it becomes clear that one would have no need to use the MAP during either of the infertile phases. Further, one can identify with some precision whether ovulation has occurred or is imminent and thus the time at which the contraceptive effect of the MAP would no longer be operable and the effect of preventing a birth would result from the abortifacient action of the MAP.

d) An Alternative to the MAP

That leaves the period of possible fertility prior to ovulation. A double dose of a high dose combined progesterone and oestrogen pill might not be the treatment of choice if the aim were only to achieve contraceptive cover for the previous evenings happening. It is relatively easy to delay or suppress ovulation beyond the stage at which intercourse in the previous 24 hrs might result in pregnancy. There are many agents that are known to delay ovulation. This was a focus of much of the early research to develop a contraceptive before the combined pill was developed with its triple effects on the cervix, ovulation and the endometrium.

In discussion with him, Professor Brown suggested that an obvious agent to use to delay ovulation, (given the early research on the pill), would be a single, moderate dose of oestrogen only. This would be unlikely to cause harm to the pregnancy if ovulation had already occurred and unlikely to cause significant problems for the woman, especially if a natural oestrogen were used - though there needs to be some further exploration of this possibility and even a trial to see what dosage would be required. It should, however, be born in mind that there is a dearth of well-researched information about the dosages of the MAP and its effectiveness. More is known about the ovulation delaying effects of a moderate dose of oestrogen than about the dosage and pharmacological effects of a double dose of the combined pill repeated over two days.

The information about identifying the phases of the woman's cycle is very useful for those who present asking for the morning after pill after a condom mishap or natural sexual intercourse. By taking a history, and undertaking a clinical examination and, if necessary, testing the ovarian hormones, (by blood test or by urine analysis), the doctor could tell them whether pregnancy would be improbable. Most of the time it is. The doctor could also tell them if pregnancy is possible on this occasion, and, if so, discuss with them at that early stage before a pregnancy test can be done, the implications.

In most instances, knowing that pregnancy is improbable, the woman can choose to avoid the unpleasantness - the nausea, vomiting, severe abdominal pain and cramping, and heavy bleeding of the MAP, and the moral and psychological issue in relation to having done something possibly abortifacient. By using knowledge of the ovulatory cycle, the woman can be freed of anxiety in many instances and perhaps learn something about her physiology and reproductive health 13.

Women who request the morning after pill can be offered the option of a serum test for oestrogen and progesterone levels and the possibility of being able to determine whether in fact pregnancy would be an improbable outcome without intervention. This option not only avoids the difficulties of the morning after pill, it also assists them to better understand their own fertility and infertility.

6. A Proposal

There is a need to establish communication and cooperation between Catholic O&G specialists and through their shared interests in these matters to establish adequate O&G research facilities guided by Catholic ethical principles to develop better, less intrusive solutions than those offered within the culture of death. This is particularly significant for the Third World which is at risk of insensitive secular reproductive health programs, the dumping of medications, and population policies that expensive and not woman or child friendly.

In this respect MaterCare needs to show leadership. I would like to propose to the directors of MaterCare International that it establish a Working Party on Ethical Obstetric and Gynaecological Research and Practice. I would propose the following terms of reference to the MaterCare Board for the Working Party:

(a) to foster and encourage research and development of technologies that are in accord with the MaterCare statutes by

(i) identifying areas where research and development that is particularly of service to a culture of life is needed and notifying members of the need;

(ii) facilitating international collaboration between members pursuing such research and development;

(iii) publishing a regular newsletter to members which, amongst other functions, is a forum for discussion of where research and development that is particularly of service to a culture of life is needed.

(b) to develop practical ethical protocols, in accordance with the MaterCare statutes, for particular areas of care in which the inherent dignity and equal and inalienable rights of women and their babies may be threatened;

(c) to foster relationships with like-minded agencies operating in accordance with the teaching of Christ and of his Church and who seek to uphold and protect equal respect for women, their babies and their spouses, and to foster authentic married life and love as the basis for a secure home for children, the unity of the spouses and the happiness of each member of the family.

Figure One: Determining whether pregnancy is unlikely when sexual intercourse has occurred in previous twenty four hours Menstrual Phase

Basic Infertile Pattern - Woman reporting dry sensation at vulva or unchanging discharge and no change yet this cycle. Clinical examination not necessary but if being done (for forensic purposes?)no strings of mucus should be seen macroscopically. Microscopic analysis of a sample taken from the cervix (by experienced doctor) would show G-type mucus. Serum and Urine Confirmation: Serum oestradiol < 440 pmol/L Urine oestrone glucuronide less than 100 nmol/24hrs Serum progesterone level < 4.9 nmol/L Urine pregnanediol glucuronide < 4 micromol/24hrs ADVISE PATIENT PREGNANCY MOST UNLIKELY IF INTERCOURSE <24HRS BEFORE

POSSIBLY FERTILE PHASE - Change at vulva to moist or slippery sensation. L and/or S-type mucus in cervix possibly with motile sperm Serum oestradiol > 440 pmol/L Serum progesterone 0.5 - 4.9 nmol/L Urine oestrone glucuronide >150 nmol/24hrs Urine pregnanediol glucuronide < 7 micromol/24hrs Peak Day - S, L and P Mucus on exam Very slippery sensation at vulva Following three days after peak Dry sensation at vulva. G and some S mucus in cervix on clinical examination. Serum progesterone < 7 nmol/L

LUTEAL PHASE Dry or sticky sensation (not wet or slippery) G-mucus in cervix Serum progesterone > 12 nmol/L Urine pregnanediol glucuronide > 12 micromol/24hrs ADVISE PATIENT PREGNANCY MOST UNLIKELY IF INTERCOURSE <24HRS BEFORE

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Endnotes

1. Willard Gates Jr "Contraception, Unintended Pregnancies and Disease" American Journal of Epidemiology Vol 143, No 4 1996; John Murtagh General Practice (2nd Ed) McGraw Hill 1998

2. Michael Christ, William V Raszka JR., and Christopher Dillon "Prioritizing about Condom Use Among Sexually Active Adolescent Females" Adolescence, Vol 33, No. 132, Winter 1998

3. Eric Odeblad cf. Evelyn L Billings and John J Billings Teaching the Billings Ovulation Method Part 2 Melbourne: Ovulation Method Research and Reference Centre 1997, p.45

5. JB Brown, P Harrisson, MA Smith, HG Burger Correlations between the mucus symptom and the hormonal markers of fertility throughout the reproductive life 1981, Ovulation Method Research and Reference Centre of Australia

6. E. Odeblad, A Hoglund et al "The dynamic mosaic model of the human ovulatory cervical mucus Proc. Nord. Fert. Soc. Meeting, Umea January 1978

7. JB Brown Studies on Human reproduction: Ovarian Activity and the Billings Ovulation Method July 2000, Ovulation Method Research and Reference Centre of Australia.

8. E. Odeblad, A Hoglund et al "The dynamic mosaic model of the human ovulatory cervical mucus Proc. Nord. Fert. Soc. Meeting, Umea January 1978

9. ELBillings "The simplicity of the Ovulation Method and its application in various circumstances" Acta-Eur-Fertil 1991 Jan-Feb; 22(1): 33-6

10. JJ Billings "The validation of the Billings ovulation method by laboratory research and field trials" Acta-Eur-Fertil 1991 Jan-Feb; 22(1): 9-15 EL Billings and Ann Westmore The Billings Ovulation Method Anne O'Donovan P/L, Melbourne, 1998

11. The three major trials of the BOM (used to avoid pregnancy)

a) World Health Organisation (1977-1981) Multi-centre - Auckland, Dublin, San Miguel, Bangalore and Manila Publication: World Health Organisation "A prospective multicentre trial of the ovulation method of natural family planning" Fertility and Sterility 1981 Vol 36, p. 152ff; 1981 Vol 36, p.591ff. 869 women 10, 215 cycles of use 2.2 Method related pregnancies per hundred women years in initiates

(b) Indian Council of Medical Research Task Force on NFP (1995) States of Uttar Pradesh, Bihar, Rajasthan, Karnataka and Pondicherry Publication: I. Bhargava et al "Field Trial of Billings Ovulation Method of Natural Family Planning" Contraception 1996, Vol 53 pp. 69-74 2,059 women 32,957 woman months of use 0.86 Method related pregnancies per hundred women years in initiates

(c) Jiangsu Family Health Institute, China (1997) Publication in English Translation: Shao Zhen QIAN, De-Wei ZHANG "Evaluation of the effectiveness of a natural fertility regulation program in China" Bulletin of the Ovulation Method Research and Reference Centre Vol 24, No. 4 pp 17-22, 2000 1,235 women 14,280 women months of use No method related pregnancies in initiates (5 user-related pregnancies) Evidence-based method-related pregnancy rate for BOM used to avoid 0-2.2 pregnancies in initiates.

12. Eric Odeblad "The Discovery of Different Types of Cervical Mucus and the Billings Ovulation Method" Bulletin Natural Family Planning Council of Victoria 21, 3, Sep 1994, p.12-13

13. D. Blake, D. Smith, M. Gudex "Fertility Awareness in Women Attending a Fertility Clinic" Aust NZ Obstet, Gynaecol 1997, 37, 3: 350

14. Stewart DC. Contraception. In: Hofmann AD, Greydanus DE, eds. Adolescent Medicine, 3rd ed. Stamford, Conn: Appleton & Lange; 1997:566-588.

15. Hewitt G, Cromer B. Update on adolescent contraception. Obstet Gynecol Clin North Am. 2000;27:143-162.

16. Committee on Adolescence. Contraception and adolescents. Pediatrics. 1999;104:1161-66.

17. Margaret C A Whit-van Mourik, JM Connor and MA Ferguson-Smith "The Psychosocial Sequellae of a Second Trimester Termination of Pregnancy for Fetal Abnormality over a Two Year Period" in Psychosocial Aspects of Genetic Counselling John Wiley and Sons: New York 1992, pp. 60-74

18. Susan Iles and Denis Gath "Psychiatric Outcome of Termination of Pregnancy for Foetal Abnormality" Psychological Medicine, 1993, 23, 407-413