What makes a family planning method “modern?”
For many decades, researchers have classified family planning methods using words like “modern” or “traditional.” These categories enable collectors of demographic survey data to record how many people are taking active steps to avoid pregnancy, while recognizing that methods vary in efficacy—and that some, based more in superstition than science, have no proven effect whatsoever. The “modern” label also determines which methods are given priority in public health initiatives, and how progress toward development goals is measured. The new family planning indicator in the Sustainable Development Goals measures the proportion of women “who have their need for family planning satisfied with modern methods.”
But who decides what is modern? Last year, David Hubacher of FHI 360 and James Trussell from Princeton University pointed out that the term is used inconsistently and arbitrarily, even between different UN entities: the World Health Organization (WHO) and the United Nations Population Fund (UNFPA) have different lists of what counts as “modern.” In an attempt to clear up the confusion, Hubacher and Trussell offered their own proposed definition. Unfortunately, their suggested solution creates more harm than good.
Their proposed definition:
“Modern Contraceptive Method: A product or medical procedure that interferes with reproduction from acts of sexual intercourse.”
The rationale is straightforward:
“Modern contraceptive methods were invented so couples could act on natural impulses and desires with diminished risks of pregnancy. Modern contraceptive methods are technological advances designed to overcome biology. In this regard, modern methods must enable couples to have sexual intercourse at any mutually-desired time.”
According to this definition, fertility-awareness-based (or “natural”) family planning methods do not count as “modern” because they require periodic abstinence. The fertility-suppressing effect of breastfeeding is likewise excluded, because it requires a prior pregnancy. Hubacher and Trussell stress that some of the methods that would meet their definition of “modern” are less effective than some of those labeled as “traditional,” but by their logic, “the word modern should not be equated with higher efficacy.”
The problem is that the word “modern” was brought into the family planning literature precisely because of its association with efficacy—although it is notable that condoms are considered “modern” by both WHO and UNFPA, despite having existed in various forms for millennia and despite being more failure-prone than many other “modern” methods.
That particular inconsistency was raised in a letter responding to Hubacher and Trussell’s proposal. Cristina Lopez del Burgo and Jokin de Irala of the University of Navarra argued that arbitrarily changing the meaning of “modern” could create confusion and potentially jeopardize informed consent. They also zeroed in on what may be the central purpose of the proposed definition: placing all fertility awareness-based methods of family planning in the “non-modern” category. The parting shot:
“We note that authors acknowledge that they have served on advisory boards for several pharmaceuticals that manufacture contraceptives (Bayer HealthCare, Teva, Merck and Co. and OCON Medical).”
In response, Hubacher and Trussell doubled down on the semantics:
“We are falsely charged with changing and redefining; we are unaware of an established definition for “modern contraceptive methods.” Our intention was simply to offer one.”
Of course, Lopez del Burgo and de Irala accused them of redefining the word “modern,” not the formulation “modern contraceptive methods.” But Hubacher and Trussell’s parting shot went on to shed further fog on the matter:
“…historical era plays no role in our suggested definition.”
Hubacher and Trussell’s proposal fueled a flurry of debate in scholarly circles, and not, strangely, over the notion of era-agnostic modernity. The classification of fertility awareness-based family planning methods has long been disputed, as much for political and philosophical reasons as for practical ones. The Catholic Church, for instance, insists that natural family planning methods are not contraceptive at all, modern or otherwise. At the UN, the Holy See has frequently expressed its understanding that the phrase “family planning” refers to the natural methods that are allowable, at least under limited circumstances. For the WHO, on the other hand, the terms “family planning” and “contraception” are used interchangeably.
One side effect of Hubacher and Trussell’s proposed definition is that it aligns closely with the Catholic Church’s definition of what makes contraception wrong: the separation of procreation from the sex act. On a practical level, the implementation of this definition of “modern contraceptive methods” in UN development policy could categorically exclude any entity working consistently with Catholic teaching from obtaining support or funding. But the implications don’t stop there.
The U.S. government’s foreign aid division (USAID) has been a strong promoter of fertility awareness-based methods (FAMs), calling for their inclusion in the “modern” classification. Earlier this year, USAID reiterated their support for FAMs, including Standard Days, a modified version of the Billings method, and the Lactational Amenorrhea Method, citing both their efficacy and a variety of ancillary benefits:
- “They do not require clinical intervention, such as hormones, devices, or procedures.
- They are controlled by a woman and her partner.
- They increase a woman’s understanding of her fertility and biological processes.
- In the case of [Standard Days and Billings], they provide the opportunity to facilitate pregnancy planning.
- FAMs can be offered through a wide variety of channels, including settings completely outside the health system.”
This generated a strong counter-argument from another group of scholars (Kirsten Austad and colleagues) who saw “this proposed change in terminology as a step in the wrong direction toward the goal of fulfilling every woman’s right to plan her family.”
Austad et al. acknowledge the lack of a universal definition of “modern methods”, but describe Hubacher and Trussell’s suggestion as “compelling.” Bearing in mind that Hubacher and Trussell see “modern” as completely separate from “effective,” Austad et al. go on to say:
“The argument for FAMs as modern contraceptives hinges on the assertion that they are ‘effective at pregnancy prevention.’ ”
So much for logical consistency. A central argument raised by Austad and colleagues is that the promotion of FAMs is not effective in situations where women are forced into sex or subject to sexual violence.
“Categorizing FAMs as modern contraceptives […] risks sending an incorrect message to women, medical providers, and policy makers that we should think of all contraceptive methods as equally effective under real-world conditions.”
In the hierarchy of confusing messaging, this ranks far below the notion that modernity has nothing to do with time itself, much less with the scientifically-proven effectiveness of an invention. But more troubling is the notion that if FAMs aren’t the most appropriate method for every situation, they should not be promoted for any situation. The horrifying fact that women and girls are sometimes victims of violence and coercion should not disqualify a happily married couple from receiving useful information about how to responsibly handle their fertility.
In their response, USAID’s Malarcher and colleagues summarized the broader implications of the debate, reaffirming their support for FAMs:
“The proposal by Hubacher and Trussell, and supported by Austad et al., means, in effect, that approaches used by men and women who prefer contraception based on a nonmedical intervention could never be recognized as ‘‘modern’’ contraception and, as argued earlier, that these methods would be left out of programming and actively discouraged by providers. These women and men would never be counted as ‘‘contraceptive users’’ by international standards and their choice would never be supported by programming efforts.”
Echoing this concern, Festin and colleagues (from a variety of UN agencies as well as USAID) pointed out that classifying all FAMs as non-modern “would have major implications for the many programs that actively promote these methods in countries.” Furthermore, they took issue with the entire basis of Hubacher and Trussell’s proposal:
“Measurement challenges remain but should not be the driving force to determine what methods are counted or reported as modern or not.”
The dispute here goes beyond measurement and even efficacy: ultimately, it all goes back to philosophy and worldview. As Hubacher and Trussell asserted, “[m]odern contraceptive methods are technological advances designed to overcome biology.” This “better living through chemistry” mindset seems awfully dated for something purporting to be modern – it’s the same sort of thinking that deemed breastfeeding to be inferior to formula, a belief that has fortunately been discredited. Hopefully, this proposed definition will meet the same fate, and international organizations will align their priorities with those who seek to understand and cooperate with biology rather than “overcome” it.