E101: The Physical Domain of Family Planning

Kirtly: What does it mean to plan your family? What happens when you get a family you didn't plan, or you plan a family that doesn't happen? At the "7 Domains of Women's Health," we are taking on the huge and critically important topic of family planning.

Every person has had a family plan. It may be as vague as "I want children someday," or it could be as focused as "We are at very high risk for conceiving a child with a lethal genetic disease, and we are choosing to do IVF with preimplantation genetic diagnosis so we can choose a child that won't suffer from that tragic disease." That is the ultimate in family planning.

Now, I'm reminded of the ancient Yiddish proverb, modified here, "woman plans, God laughs." Of course, most children that are unplanned are very wanted. So the planning thing is complicated, with at least 40% of the pregnancies in the world being unplanned.

I'm Dr. Kirtly Jones from obstetrics and gynecology at the University of Utah, and I'm a reproductive endocrinologist. I've spent my career thinking and clinically practicing family planning. I've had as my professional North Star that every child deserves to be wanted and planned for, and every person deserves to have the child or children that they want.

And with me is my co-host and expert in women's health, Dr. Katie Ward. Katie has a doctorate in nursing practice and a PhD in anthropology and a clinical practice in women's health. We met years ago, once upon a time, in a family planning clinic.

Katie: How perfect.

Kirtly: Perfect for this topic. The World Health Organization's statement on family planning says, "Family planning allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through the use of contraceptive methods and the treatment of involuntary infertility. A woman's ability to space and limit her pregnancies has direct impact on her health and well-being as well as on the outcome of each pregnancy."

Of course, the word we should be using here is "person's ability," as men and other gendered persons have rights to the process.

As I trained in reproductive endocrinology and infertility, I also had an interest in contraception and family planning. And I took a moonlighting job in a family planning clinic for refugees and underserved women.

My own pregnancy was planned to the minute. Well, I planned it. My husband wasn't entirely aware of my plans. And I didn't really plan it perfectly, as I thought it would take a while for us to get pregnant and we were past our peak fertile age. But it was one and done, and I arrived as a brand-new faculty member with a baby on board. So it was planned. It was just sooner than I had planned.

So, Katie, how do you define family planning?

Katie: I mean, I think it's hard to improve on the World Health Organization's statement, but I've been thinking about how the meaning of that term, "family planning," has felt like it's changed over my career.

So I felt like early on when maybe we had fewer contraceptive methods and more people were getting pregnant young or more often, "family planning" implied going to the clinic where you were going to get some kind of contraception to prevent or space pregnancies.

And over the course of my career, we have new contraceptive methods, and it's become better accepted, and teen pregnancies are down. And most people in the U.S., at least, have access to contraception, and they use it. It feels like the meaning has almost flipped. When patients are on my schedule and it says that they're scheduling for family planning these days, that usually means that they're wanting to get pregnant and maybe starting to wonder if they're having some challenges with that. So they're not using that term and scheduling appointments for contraception, but rather to try and get pregnant.

So the vocabulary has come along with the whole World Health Organization definition.

Kirtly: Yeah, and I think that's actually wonderful. It's just a little bit hard for us who trained in family planning, and it was coincident with contraception.

Katie: Yeah. And now I'm seeing another shift that's starting to happen that I think we're going to explore in future segments on family planning, but really an effort to move toward talking to people about a reproductive life plan, which is kind of broader and maybe captures more what the World Health Organization is saying.

But you consider your goals for your whole lifetime, whether you want children at all and when and how many, and how those align with staying healthy before you get pregnant. So it's a little bit more of a long-term perspective, and it's targeted at both men and women, recognizing that there are health issues for both parents in this situation.

The other thing I'm seeing that is new is people want reassurance. They don't necessarily want to get pregnant right now, but they want reassurance that they'll be able to do that in the future.

Kirtly: Yeah, absolutely.

Katie: Which I think is kind of an interesting dynamic that just has changed over the course of my career.

So, yeah, I think when we talk about family planning, it's a wonderfully vague phrase, and it depends a little bit on the context. It can mean preventing pregnancy, achieving pregnancy, planning for a future pregnancy. All of those maybe in the same lifetime, right?

Kirtly: There's a fabulous episode on "Friends" where Rachel has got her plan down to exactly when she's going to meet the person of her life, when she's going to get married, when she's going to have her first baby. And of course, things don't always work out that way.

Well, let's get down to the physical part. I'm going to assume that all of our listeners to the "7 Domains of Women's Health" podcast know where babies come from. But here's a little story.

When our son was about 5, I asked him if he knew where babies come from. I had the kid's book already. It was on his bookshelf, but he hadn't found it. I was ready for a lesson. I was in total teacher mode. And he looked at me earnestly because he's earnest at 5, and said, "Mom, of course I know." Well, lesson over for now.

I tried again at 7, and he said the same thing. And this time, I asked him where babies come from. "Well, Mom, the doctor sticks the needle in the lady's ovary to get an egg and adds the sperm and puts it back in the uterus and cuts the baby out when the baby's ripe." Well, I told him that that was where some babies come from.

He was paraphrasing what he imagined he heard over the phone because I was an IVF doc, and I was often gone on weekends for egg retrievals and embryo transfers.

I told him that that was not where he came from. And then I got out the book and went over it with him. He looked at me shocked, and he said, "You lied to me, and what you and Dad did was sick and wrong."

I flunked parental sex ed. So, Katie, did you have more luck with your kids?

Katie: Well, maybe I did. Did they say it was sick and wrong? I don't know. But I raised four boys and one girl. And over the years, I developed what I actually think is a great talk for talking about sex with young men. Maybe I'll record it separately and link it on our webpage.

Kirtly: You should.

Katie: It's long when I get rolling with it. It would take up the whole episode. But in short, I called it the . . . Originally it was the 3 Ps, now it's the 5 Ps. But the original idea was that if you wanted to use your penis, a P word, you needed to learn about three other P words, and those were permission, protection, and pleasure. The two I've added more recently are power and porn.

Kirtly: Oh, good. I want to hear this talk. We're prepping this up for an independent 7 Domains of Talking to Your Kids About Sex.

Katie: It's a good talk. When you got your boy in the car and they're there and something comes up. For my daughter, she grew up around that talk. I mean, my sons would actually bring their friends over and ask me to do the talk.

Kirtly: To do the talk so they can hear their mother say that word "penis"? Oh, geez.

Katie: So my daughter grew up around it. And like you, I was a nurse practitioner who was working in family planning and teaching gynecology. So sex ed was just dinner conversation for her. And as a result, she became the person that her friends came to for information because she had that mom. I had condoms and emergency contraception in the medicine cabinet for anybody to pick up.

In fact, she got a text from a friend of hers not too long ago that she shared with me where the friend said that she was thinking back on how open I was and said sometimes my frankness was embarrassing. But now she is so grateful that she had a place where she could come ask questions and have those conversations.

Kirtly: Well, I think if your five and my one are successful so far in their life plans about family, then we were successful, or we were lucky or successful if they're doing okay in this regard.

Well, basics. You need eggs of good quality, at least one. So you need eggs. Now, that's why when you get older, they're not a very good quality. But you need eggs, at least one. You need sperm of good quality, hopefully millions if you're going to do it the traditional disgusting way that my son was all upset about. But you only need one if you're going to do IVF, which is what he hoped had been done, of course.

Now, you need a genetic combination of the egg and sperm that leads to a viable embryo. And this is important to know that at least 50% of fertilized eggs never make a baby. They're not viable, and they don't make a viable child. So there are a lot of mistakes. And some people, because of egg or sperm or other things, make more mistakes, and so they can't make a viable embryo.

You need fallopian tubes that can get the preimplantation embryo to the uterus. You need a uterus that can carry a baby. You need a mother in good health, because some diseases cause miscarriages. You need an environment with enough food, air, and water, because contaminated, not enough food can lead to pregnancy loss. Not enough or clean enough air or water can lead to stillbirth.

And you need shelter, and you need a safe birthing environment. It's no good to go all this business and then lose your mom or your baby because of a difficult birth.

So you need all those things. And if you can kind of plan those things, that would be good.

When should a person start planning? Well, it's never too soon. It may be a decision to postpone sexual intercourse until you're ready to have a family. And if you've trained your kids well, then they know that any sexual encounter with a penis and a vagina, with eggs and sperm, could lead to a baby. So they should start in their early teens when the pressure to have sex begins and say, "I'm not going to do this until I'm either protected or until I can have a baby." Good luck with that. And it should certainly begin before a person is at risk for making a baby, for men and for women.

A life plan from 15 to 50 is at risk for things that go bump in the night, unplanned things that happen in life. Be prepared for not getting your Plan A and have a Plan B, or develop resilience for what might come: too many babies, no partners, loss of a partner, a child with significant physical or medical conditions. The list can go on and on.

So what kind of options do you have in the family planning/contraception part, or long-term family planning? Katie, take this on.

Katie: Well, man, there are so many different contraceptive options, right? I have a colleague who used to sort of talk about it as a smorgasbord, and she always gave the analogy that the more things that were on the smorgasbord, the more likely you were to find the one that worked for you. Sometimes that's the challenge, is that there are lots of options and it's hard to sort them out.

So there are a couple of ways of kind of parsing this that I think are really helpful. One is an initiative put together by the March of Dimes and the CDC. It's called One Key Question. So this is aimed at healthcare providers, and the idea is that anytime you go in for any medical visit, that we ask as providers, both males and females, "Do you plan to have a pregnancy in the next year?"

And if so, we can talk about important health practices like what vaccines you might want to get ahead of time, health habits that might need changing, environmental exposures to consider for women, prenatal vitamins, which are actually more important to take between pregnancies than just during. So that's kind of one approach.

For women who don't want to get pregnant, then a follow-up question about . . . I usually ask, "How important is it to avoid pregnancy right now?" And that helps me decide what methods I'm going to start talking about first.

So we have many family planning options or birth control options that are more than 99% effective. If someone tells me it's very important, it's the most important thing to not get pregnant right now, I want to start with those top tier options and move down in effectiveness if none of those are acceptable.

And I want to just give a mention here since we're going to be talking about all these methods, but if people are curious, there's a great resource called bedsider.org. This is a website that you can go to and it's comprehensive. It has all kinds of really cool tools for comparing methods, seeing how they work, how they fit in your life, what they might cost, what are the side effects, all the things that you need to know to figure out what's going to be best for you at this time in your life.

Kirtly, you taught me this some time ago, that nobody uses just one method in their whole life. You have different methods for different phases.

Kirtly: Absolutely.

Katie: Sterilization is the only thing that's permanent, and everything else is temporary. And some things fit better at different times than others. So Bedsider can be a nice resource for sorting out, given all those goals, what's going to be the thing for you right now.

I know we're going to touch on a lot of methods throughout this series, but I do want to go off on a little tangent right now about the physical effects of hormonal contraception. And that's because this feels really urgent to me.

I'm seeing a really common set of concerns that patients bring into clinic. And because I have a reproductive-age daughter, she's been telling me how much she gets targeted with this anti-contraception content on social media.

So what seems to be happening is that influencers are describing their own terrible experiences with contraception, whether that's depression or weight gain or fears that it changed their future fertility.

And there's this thing that we call a nocebo effect going on where someone prepopulates these negative ideas in your head, and you're kind of predisposed to find them in your own experience.

I think this influence campaign is actually more insidious than just individual people sharing their experience on TikTok or Instagram.

Kirtly: Oh, I think it's targeted. I think it's deliberate to make people unsure about using hormonal methods, and I'm quite concerned about that.

Katie: I am too. So what we've seen is a lot of companies developing fertility tracking apps. And these can be using data that you insert from your wearable device or just that you enter on your own. Unlike a pharmaceutical company that has to spend millions, maybe billions, of dollars to bring a product to market with rigorous, an app is pretty cheap to develop. So then if you've got your app, all you need is some strategically placed content creators to plant the seed that hormonal contraception is bad and their app is better.

I think the problem is that people are trading highly effective contraception for something that requires significant time, attention, and perfect use. And without all that, those apps can fail frequently. So I really worry that people are giving up on reliable contraception based on being influenced.

Hormonal contraception, we know, has a lot of benefits. First and foremost, and I don't think we talk about this enough, it cuts your risk of ovarian cancer up to half if you use it for just a few years in the course of all your reproductive years, and it reduces your risk of many things that can lead to infertility.

So Kirtly, you were just talking about what you need to get pregnant. Women who use birth control pills have decreased risk for ovarian cysts, endometriosis, PID, and ectopic pregnancy. The treatment of these things can cause fertility challenges down the road. So in many ways, pills help preserve your fertility by protecting you from some of those conditions. 

People who use the pill or the patch or the ring, sort of wearable pills, have fewer menstrual-cycle-related complaints like cyclic migraines and PMS, and they have control over when they have a period. And since the Affordable Care Act, many pills are available for free.

So I want to sing the benefits of birth control pills a little bit.

Kirtly: Oh, yeah.

Katie: And then the other thing that I think about kind of with my anthropology hat on is that modern women in first-world countries are ovulating maybe more than four times as often as our ancestors did. Prior to modern contraception, most women spent the bulk of their reproductive years either pregnant or nursing, and they didn't ovulate as frequently. And we know from studies on women who never had children and that have frequent uninterrupted ovulation is that they're at increased risk for ovarian cancer.

So it does drive me a little bit crazy that when we talk about natural family planning, that naturally ovulating month after month is not natural. It's not what we were really designed to do. We were designed to have breaks from ovulating for extended periods of time. 

Kirtly: Years and years. We often breastfed for years, and that was the only way children could survive. And of course, many of our children died. And so what is natural isn't particularly desirable.

Katie: Yeah. So anyway, thank you for letting me just get on my little soapbox about hormonal contraception.

Kirtly: Well, this is the physical part, so this is all physical. We're good.

So what happens if it doesn't work out as planned? Let's say you're using this super app, which takes much time every single day. Taking a pill takes a nanosecond. But doing these apps, you didn't do it exactly, or you just had somebody who was so convinced they wanted to have sex that you didn't play by the rules, which is a guarantee that it's not going to work, and you're going to get pregnant. And that's where Plan B comes in. Not necessarily the product Plan B, but your Plan B, your planning B.

If you become pregnant and you feel you cannot medically, socially, economically, or physically raise a child, you do have options. And in this country, abortion is an option. Adoption is an option. And there are ways, if there are physical, economic, or medical risks to you, that you may choose to work around with your clinician. So you need to be able to act on your Plan B, particularly if you're using a method that is not 100% successful, which is hard.

So how do you make a plan? Maybe for personal, psychological, social, or religious reasons, you choose not to make a plan and absolutely say, "I'm going to let come what comes." Fine.

In the history of humankind, people have been planning their families for as long as we have documented records or paleontological records. So people have had pretty strong ideas about whether they wanted or didn't want children.

Fertility symbols have been found throughout ancient human settlements, suggesting that having children was wanted. Similarly, there are findings of efforts by people to avoid having children. And of course, history of who we were is kind of interesting.

Katie: Yeah. I mean, it's so important. Our ancestors, Homo sapiens, evolved to be a very slow-reproducing animal. So prehistoric societies, and we know this by looking at the few groups that still sort of live similarly, probably actually only produced four to six offspring. Puberty was in the upper teens. You didn't become reproductively capable until later. Babies were breastfed, as we talked about, for three to four years exclusively. So that has this way of spacing pregnancies through lactational amenorrhea. And then, sadly, probably half of those prehistoric children didn't make it to reproductive age themselves.

Kirtly: Oh, and we were starving, intermittently starving, and that blocks ovulation as well. People who are starving often don't ovulate.

Katie: Yeah, and so that was the environment that we lived in for truly millions of years. And the population grew very, very slowly at that rate. And so that's kind of our reproductive history.

If we go back to the Paleolithic period, where we start to sort of have some evidence of how people were living, so 25,000 to 40,000 years ago, that's where we start to see these figurines that we call the Venus figurines and think of as fertility goddesses. At least that's what we assume they represent. Truth is, we don't actually know. But these artifacts, I'll just note for everyone on the paleo diet, are not skinny.

Kirtly: Oh, no. I had a copy of one of those on my desk. She was quite round. Very round.

Katie: That's for another podcast, but I think if you're going to have six pregnancies and you hope that three babies survive, you really might be wishing for fertility. And that's hopefully what those little figurines are there for.

But as humans became more settled and life revolved around agriculture and increasing urban centers of activity, puberty began to get younger and younger. People became reproductively mature earlier. Breastfeeding was shortened or maybe passed off to somebody else altogether, and fertility rates increased.

I always think of Queen Victoria, who very famously hated being pregnant and . . .

Kirtly: She hated sex, too. She'd close her eyes and think of England.

Katie: But she did love her husband.

Kirtly: Sorry.

Katie: But she had nine children who survived, and I think what that brings up is that sooner or later, human societies need to start to think about how they restrain family size. So if you're having 10 or 17 pregnancies in a lifetime, that's very different than the conditions that our ancestors were in.

What we do know is that humans have been trying to manage fertility for thousands of years that we have records. We have Egyptian papyri from 4,000 years ago that describe contraceptive methods. And these actually probably worked. They had ingredients, acacia, that ferments into lactic acid, which is spermicidal, and it was often mixed with some other yucky stuff. Dung. Dung might have been spermicidal too.

Kirtly: It might work in a unique way.

Katie: Yeah, just get away, stay away. But there are medical texts from all around the world that list dozens of kinds of contraceptive methods. And we have historical records, again, from all across the globe that describe herbal remedies that bring on delayed menstruation. So without a positive pregnancy test, being late and being pregnant were indistinguishable.

Healers would know that herbs that you'd collect and brew into a tea might bring on your menses. And they didn't see these as causing abortion, but just bringing about a late menstruation.

And there was one, silphium, that was in northern Africa that was very effective maybe as a contraceptive. It worked by preventing implantation. For that reason, it was really desired, and it was worth its weight in silver. The records say the coins were stamped with this herb on it and it was harvested actually to the point of extinction.

So humans have been using medicines as contraceptives for as long as we have written records. And this is critical because pregnancy and childbirth were dangerous, as we've talked about. So if you have a 2.5% chance of dying with each pregnancy and you have 9 or 10 pregnancies, that gives you the odds of one in four that you're going to die in the process of giving birth over your lifetime.

Spacing pregnancies, delaying them when you weren't healthy, or preventing them when you already had as many children as you could feed, it was survival.

When contraception failed, the reality was pretty grim. We see in the Middle Ages foundling hospitals develop across Europe, and these were built specifically to give desperate parents an alternative to infanticide. And infanticide was probably happening more than we want to talk about.

The London Foundling Hospital was founded in 1741, and it took in, in its early years, nearly 15,000 children. Two-thirds those, around 10,000, according to their records, died. So I'm not sure the foundling hospitals were that much better than what they were replacing.

Kirtly: Well, they died for a number of reasons. Bad water and bad food. But these are often infants, brand-new newborns, and there was no breast milk. There wasn't any way you could feed these babies. And it's really quite stunningly sad, really.

Katie: But it is a record, I think, of just how common this was, that people were having pregnancies that they produced children that they couldn't raise.

There's a foundling hospital in Florence. It's now a museum that you can visit, and you can see there's this iron grate where they would pass the babies through so people could sort of anonymously drop off an infant. But that hospital did keep records that showed that 50% of those births to mothers who relinquished their infants were to mothers who had six or more children.

So I think this complicated question is never about "there are people who have babies and people who don't." They're people who have more children than they can feed and are having to make different choices.

Humans have always sought to control when they had children. What's changed now is not the desire to plan. It's that we finally have safe, effective methods to do it.

Kirtly: And as you mentioned earlier, we've really seen a change from when I started practicing 40-some years ago, 50 years ago, in what was available and how good people were in using them. So I think we've really seen a change just in my career.

Well, here we are in the 21st century, so let's make a plan. So children not ever? That's your choice, or you and your partner's choice. No children ever. Certainly that's chosen by priests in some religions, and other persons may make that choice for personal or medical or genetic risk factors.

They may completely abstain from sexual behaviors that could create a pregnancy, or there's the option for permanent sterilization for men and women. It's not perfect, but it's getting there with a failure rate of about maybe one in a thousand sterilizations. And the option for pregnancy termination, or adoption, or happily resolving that you're going to raise that child exist.

Well, what about children not now, not this month, not this year, pretty soon, or not for years? How one chooses the method . . . and Katie, you talked about this before. How you choose the method is a function of how soon you want a baby and how badly you want to prevent a pregnancy.

So you can use methods such as condoms or barrier methods, which are not highly effective, and the risk of failure is that you have a child just a little bit early. That might be perfectly welcome for you, or not what you planned. You're planning on moving to God knows where and getting settled and then have your baby. That was me. But it came on the way, so there you go.

Or not for 10 years for really important reasons, like waiting for a kidney transplant or a heart transplant, and you want it to be highly effective. Then you need methods like an IUD or an implant with failure rates of about one in a thousand, equal to sterilization.

Male methods may actually be on the horizon for methods that are going to be effective as oral birth control pills. And if you combine, if both men and women are using something, then you get diminishingly tiny chances of a pregnancy happening.

But don't wait too long, for women over 40, as the option will close. Unless you want to use something like egg donation, in which case the options stay open for a pretty long time.

Let's say you want a baby right now. If you're healthy and financially and environmentally stable enough, make sure you've got your vitamins and make sure you get your vaccinations, and then get started with unprotected intercourse, or a sperm donor, or an egg donor, or IVF. If the ordinary way, thinking back to my son's sex ed, doesn't work, have a backup plan.

So I'm thinking of a postcard that I have on my fridge from Angry Birds, and it says, "It was a calculated risk, but man, am I bad at math." So kind of know how likely things are to happen. We're going to talk about this in the Intellectual Domain. We'll talk more about numbers.

But if you want to plan your family, you've got to have a plan. So make a plan.

We're going to be exploring all 7 Domains of Family Planning. Hang in there with us on this powerful idea of planning your family wherever you get your podcasts, or hang with us at womens7.com.

We're grateful that you're with us, and we want all of our children planned, wanted, or not, as we think about how to be healthy and happy women and men and families going forward.