When an Israeli woman asks her gynecologist about contraception, either to space her children or avoid pregnancy altogether, she will probably be given a prescription for hormone pills or an intrauterine device (IUD). Several alternative methods available in the US are not easily obtained here, and as a result some gynecologists are not even familiar with them. Even fewer know about natural methods of contraception that require a short course and some basic equipment instead of conventional pills, patches, sheaths, injections or invasive devices.
This approach may be preferable for those who fear the health implications of oral contraceptives that - according to a meta-analysis of 34 separate studies published in the October issue of Mayo Clinic Proceedings - can increase the risk for breast cancer by as much as 44%. The study, whose lead author was Dr. Chris Kahlenborn of Altoona Hospital in Pennsylvania, said sustained use of The Pill may put women under 50 at significantly increased risk for breast cancer, especially those who take them before having a first child. The article urged doctors to better inform patients of the risks associated with oral contraceptives.
Michal Schonbrun, a self-employed Jerusalem-based reproductive health educator with a master's degree in public health from California State University (which she began at the Hebrew University-Hadassah Braun School of Public Health and Community Medicine) says women should have the choice of other contraceptive methods.
"I teach women body literacy," says the California-born Schonbrun, who has lived in Israel for 25 years. A public education specialist certified by the US National Commission for Health Education Credentials, she is one of 10,000 such professionals in the world, and of only two in Israel. She is currently training six more women - four of them Orthodox Jews - in a year-long, 150-hour course to become reproductive health educators.
"JUST AS one has to learn to read and write to live in this world, women and men also need body literacy to know how their bodies work," she says in her Jerusalem apartment. "But today, many women know little about their anatomy and how it functions. I've even done workshops with female doctoral students who had no idea about this subject. I feel this is part of my mission, as more young girls are taking hormones for acne, or for irregular or absent menstrual periods. Many will not be able to get pregnant because they have a hormonal problem masked by the Pill."
Some women prefer something natural, without side effects. Although 80% of Schonbrun's clients - haredi, modern Orthodox and secular women - come to learn about such natural methods of contraception, she is also well familiar with conventional approaches, and advises them to look for those that are not readily available in local pharmacies.
"Couples also come to me because they have had trouble conceiving; they don't know when the woman is fertile." She doesn't know the official statistics on the annual number of legal and illegal abortions resulting from failed contraception. Add to that the number of Postinor (morning-after pills) taken by women who fear they have conceived. "It's hard to know, but I believe it is higher than we think. I've met many women who got pregnant even though they had an IUD, which is considered to be a very reliable contraceptive. While some couples use condoms, very few use other barrier methods such as spermicides, diaphragms, spermicidal sponges or female condoms, which are effective in 75% to 95% of cases, especially if used properly and consistently."
MOST HORMONAL methods, adds Schonbrun, a divorced mother of a 20-year-old daughter, are considered to be about 96% effective, and doctors prefer them because they are interested in providing "the easiest, most hassle-free method, one that they don't need to spend time explaining. Society values technology, convenience and simplicity, and doctors prefer simple solutions."
It isn't a coincidence that the most popular contraceptive method - hormones - reap the most profits for pharmaceutical companies, she says. "I am not absolutely against the Pill, despite possible health risks and side effects, but many women don't know they have other options."
She is not enthusiastic about a hormonal pill already sold in the US and due to arrive in Israel, called Seasonale, that keeps fertile women from having menstrual periods more than four times a year.
"A pill is taken every day, with a break every few months. Suppressing periods is very fashionable, but I don't believe in the theory behind it. How can it be that the most natural aspect of the feminine body may be on its way to extinction?" says Schonbrun. "These products are coming out because someone is set to make a lot of money from them."
While some European countries and some health maintenance organizations in the US provide some contraceptives free, these are not included in Israel's basket of health services; only girls under 18 can get free contraceptives from their health funds, she said.
"I think the reason is that this country goes out of its way to encourage childbirth; Israel is at the forefront of the world in assisted reproductive technologies. But I am worried about the health dangers of mega-use of these hormones, including the over-stimulation of ovaries and breast cancer.
The most common hormonal methods are the Pill - third-generation, low-dose estrogen and progestin combinations or only progestin. "But low-dose pills," she continues, "are causing vaginal atrophy, and there may be some correlation between them and women's sexual pain disorders."
Hormonal pills for men are in an advanced stage of development, but Schonbrun doubts whether any Israeli men will be willing to take them.
Contraceptive hormonal patches are worn for a week at a time. The old Dalkon Shield IUD, which caused much trouble a few decades ago, has been abandoned, and others such as Periguard and Gynefix are available here. They have copper strings and coils, and the metal's ionization inhibits sperm motility, preventing them from impregnating the egg.
The new Nuva vaginal ring, which releases progestin and estrogen, arrived in Israel recently. It is worn for three weeks, and is then removed by the woman herself, who replaces it after her period. But this may cause blood spots, which upsets observant women whose family purity ( nidda) practices are thereby disrupted.
Depo Provera, a hormonal injection given every three months, was never used much in Israel, says Schonbrun. The Norplant hormonal subcutaneous implant is even less popular, she adds, even though it is good for women over 45 who smoke. But few doctors have the needed experience with the minor surgical procedure needed to insert it.
"In my 20 years of practice here, I have met only two women who told me they use Depo Provera or Norplant."
AS FOR barrier methods, silicone/rubber diaphragms inserted just before intercourse are difficult to find here, and spermicide creams are even harder to get, said Schonbrun, who refers women to the handful of medical suppliers and pharmacies that can provide them. Diaphragms have to be fitted by a gynecologist, as there are different sizes, and most doctors aren't willing or able to do this. Because they cover the cervix, they also can protect against sexually transmitted diseases - another advantage that is hardly ever mentioned.
Female condoms are used in the Third World, but not in Israel. US women can buy vaginal contraceptive film - a small square of thin transparent plastic treated with spermicide; before intercourse, one is inserted close to the cervix, where it turns into a gel that kills sperm. It doesn't have to be removed, as it disintegrates after several hours. The film, which costs about 50 US cents apiece in boxes of 12, is not available in Israel.
As for cervical caps, they are imported by only one Israeli midwife living in the south, who also fits them. Spermicidal sponges are between 75% and 95% efficient and can be purchased over the counter, but are expensive, costing NIS 15 apiece in packs of three. Glovan is a cheap, sticky and unesthetic spermicide that can be bought without a prescription and inserted soon before sex. It and sponges are the only contraceptives besides condoms that can be bought over the counter in this country.
"Even in Africa there are more birth control methods available," notes Schonbrun with irony.
The most popular contraceptive methods used by married couples in the Western world - vasectomy in men and tubal ligation in women - are hardly used here for religious and psychological reasons, and because they are almost always irreversible. They can be done privately at a cost of about $5,000 (and at health fund expense if a woman's life would be endangered by another pregnancy).
Schonbrun, who is not Orthodox but consults with religious experts, says it is halachically permissible for mothers to space pregnancies.
"Any rabbi will give permission to wait a year between births so women can recover. But they usually take hormone pills. These, however, contain estrogen that can affect the quality and quantity of breast milk." Some women still believe that breastfeeding will protect them from getting pregnant for at least six months, but this isn't reliable. "I know of many haredi women who breastfed and got pregnant."
WHAT IS the natural method that Schonbrun teaches? Women for years have known about the "rhythm method" that monitors the individual menstrual cycle to predict the most fertile time of the month. During those days, one avoids pregnancy by using a barrier method of birth control, or by avoiding sex altogether. Women with a regular 28-day cycle will produce an egg about 14 days from the start of each period. But just tracking one's cycle is usually not accurate, as few cycle patterns are exactly regular.
Ovulation predictor tests are available in Israeli pharmacies, she says. These urine-testing kits can help women time intercourse so they can get pregnant, and in the US there are saliva tests for this purpose. But neither of these home kits, she insists, is accurate enough to be used for contraception.
Schonbrun first learned of fertility awareness 25 years ago, when Toni Weschler wrote a definitive book on the subject. Schonbrun teaches a combination of the basal body temperature method, in which you keep track of your temperature with a special, highly accurate digital thermometer every morning before getting out of bed (body temperature rises two days before ovulation), and the ovulation method, in which you check cervical secretions (mucus) to determine when you ovulate. Combined, this "sympto-thermal method" is more accurate than each separately, she says. To avoid pregnancy, she says, one must abstain from vaginal sex for 10 to 13 days each month.
"Crypts or crevices in the cervix release fertile or anti-fertility secretions at different times of the month. Most women are infertile for most days of their cycle, as a sticky, thick, natural secretion acts as spermicide. During only a few days a month does the body release fertility secretions that are more liquid and transparent, with the consistency of egg white."
Four hours in private sessions or in a group for up to eight hours are enough to learn the method.
"You can't learn it from a book; you must learn to apply the principles on your own body, taking a couple of minutes a day to fill out a temperature chart and examine the secretions with your fingers. Every woman has hormonal variations." She says the sympto-hormonal technique is 80% to 100% effective in preventing conception, depending on whether you use a backup method or abstain during fertile days.
The technique is not for everybody, "but is an alternative for any woman who doesn't want to introduce artificial hormones into her body," concludes Schonbrun, who charges NIS 800 for her three-session course over six months and long-term followup. Her Web site will soon be up at www.poriyutivit.com, and she can be e-mailed at firstname.lastname@example.org.