THES" Michigan State University This is to certify that the thesis entitled METHODS OF CONCEPTION REGULATION AND SELF—ESTEEM AMONG CATHOLIC COUPLES presented by REV. JOSEPH TORTORICI, O.P. has been accepted towards fulfillment of the requirements for MASTERS FAMILY STUDIES degree in Major professor Date JULY 13, 1979 0-7 639 ovmnua FINES ARE 25¢ PER DAY , PER ITEM Return to book dr0p to remove this checkout from your record. METHODS OF CONCEPTION REGULATION AND SELF-ESTEEM AMONG CATHOLIC COUPLES BY Rev. Joseph Tortorici, O.P. A Thesis Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF ARTS Department of Family and Child Science ABSTRACT METHODS OF CONCEPTION REGULATION AND SELF-ESTEEM AMONG CATHOLIC COUPLES BY Rev. Joseph Tortorici, O.P. The major purpose of this study was to investigate whether or not the use of natural methods of conception regulation has a positive effect on the personal self-esteem of married couples and on their marital rela- tionship. The major objective is to determine if there are any differ- ences in the self-esteem levels between couples who use natural methods of conception regulation and couples who use contraceptive or surgical means of conception regulation. A Two-Way ANOVA.was used to analyze the hypotheses. Post-hoe procedures were employed to further test differences in cell means. The results of the study suggest a joint occurrence between being well adjus- ted in marriage, higher self-esteem and the use of natural methods of conception regulation. Further, that among couples with higher marital satisfaction, those who use natural methods are statistically discernable from well adjusted couples who do not use a natural method. Couples who have been sterilized evidence both lower self-esteem and marital satisfaction. ACKNOWLEDGEMENTS Appreciation is expressed to my Adviser, Dr. Donald Melcer for his gentle guidance and support throughout the planning and completion of the study. Appreciation is also expressed to my other Committee members, Sister Mary Honora Kroger, R.S.M., Ph.D. for her challenging guidance and patient support; Dr. Jane Oyer, and Dr. Robert Boger who contributed valuable insights for the final writing of the Thesis. Thanks are given to Dr. Howard Teitelbaum for his generosity in serving as statistical consultant. Gratitude is expressed to Mrs. Yvonne WOodley whose assistance was inval- uable in data collection, correspondence with subjects and preliminary typing. Deep appreciation is extended to the couples who participated in the study without whose efforts and willingness to share their marriages this study would not have been possible. Final appreciation is expressed to the many persons and communities involved in Natural Family Planning who over the years have contributed to my education in this area of study. ii DEDICATION To married couples who use natural methods of conception regulation, and who witness through their commitment in married life to the enduring values of human life. iii TABLE OF CONTENTS PAGE LIST OF TABLES V1 LIST OF ABBREVIATIONS viii CHAPTER I INTRODUCTION 1 General Statement of the Problem 1 Purpose and Objective 3 Research Hypotheses Under Investigation 3 Assumptions 4 Conceptual Definitions of Terms 5 Natural Methods of Conception Regulation 5 Contraceptive Methods 6 Self-Esteem 6 Marital Satisfaction 7 Overview 8 II REVIEW OF THE LITERATURE 9 Natural Methods of Conception Regulation 9 Related Literature on Contraceptive Behavior 14 Nature of Self-Esteem 18 Marital Satisfaction 20 III METHODOLOGY AND DESIGN OF THE STUDY 24 Introduction 24 The Sample 24 Definition of the Population 24 Description of the Subjects 25 Selection Procedure 27 Sampling Procedure 28 Data Collection Procedure 29 Responding Sample 30 Specific Problems of Sampling Affecting Design 31 Research Design 32 Description of Research Instruments 33 Tennessee Self Concept Scale 33 Family-Marital Adjustment Instrument 34 Family Planning Questionnaire 35 Statistical Hypotheses 36 Operational Definitions 37 Marital Satisfaction 37 Self-Esteem 37 Methods of Conception Regulation 38 iv IV. RESULTS OF DATA ANALYSIS Introduction Analysis of the Data Results of the Family - Marital Adjustment Instrument Content Analysis of the Family Planning Questionnaire Summary of Findings Discussion of Results Summary Comments V. CONCLUSIONS, LIMITATIONS OF STUDY AND SUGGESTIONS FOR FURTHER RESEARCH Introduction Conclusions Generalizability Limitations of Present Study Suggestions for Further Research APPENDIX A: APPENDIX B: APPENDIX C: APPENDIX D: APPENDIX E: APPENDIX F: APPENDIX G: APPENDIX H: APPENDIX I: APPENDIX J: BIBLIOGRAPHY INITIAL LETTER CONSENT FORM PERSONAL INFORMATION FORM FAMILY - MARITAL ADJUSTMENT INSTRUMENT FAMILY PLANNING QUESTIONNAIRE (FORM A) FAMILY PLANNING QUESTIONNAIRE (FORM B) RESPONSES TO OPEN ENDED QUESTIONS (FORM A) REASONS GIVEN FOR CHOICE OF CONCEPTION REGULATION METHOD RAW SCORES ON TSCS RAW SCORES ON F4MA 39 39 39 44 56 58 64 68 68 69 71 71 74 77 79 80 81 83 88 93 95 96 97 98 TABLE 3.1 3.2 3.3 3.4 3.5 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 4.12 4.13 LIST OF TABLES Educational Level Achieved for All Subjects Joint Income for All Couples Actual and Desired Family Size According to Group Methods of Conception Regulation Used by Couples Methods of Conception Regulation Used - Comparison of Present Sample and a National Sample Results of Analysis of Variance Design Table with Self-esteem Scores by Level of Marital Satisfaction and Method Group Self—esteem Mean Scores for Husbands and Wives with High Marital Satisfaction Mean F—MA Scores for Husbands and Wives Comparison of Mean F-MA Scores Mean FeMA Scores for Husbands and Wives (High, Medium.and Low) Satisfaction with Method Used Individual Confidence with Method Used Spouse Agreement on Method Used Arguments about Method Used Method Helps Marital Communication Issue of Conception Regulation Interferes with Marital Relationship Present Practice of Conception Regulation Enhances Marital Relationship vi PAGE 25 26 26 27 28 4O 40 43 44 45 45 47 47 48 48 48 49 49 LIST OF TABLES (Cont.) TABLE PAGE 4.14 With Understanding and Love 50 4.15 With Some Criticism and Negative Feelings 50 4.16 With Silent Resentment 50 4.17 Frustrated 51 4.18 At Peace 51 4.19 Misunderstood 51 4.20 Guilty 52 4.21 Accepted and Loved 52 4.22 Analysis Table of Statistical Hypotheses 57 vii TSCS: F-MA: FPQ: MGb : LIST OF ABBREVIATIONS Tennessee Self Concept Scale Family-Marital Adjustment Instrument Family Planning Questionnaire Method Group A - Couples Using Natural Methods of Conception Regulation Method Group B - Couples Using Contraceptive or Surgical Means of Conception Regulation viii CHAPTER I INTRODUCTION General Statement of the Problem During the past decade there has developed a growing interest in the topic of natural family planning or natural methods of conception regulation. The topic of natural methods of conception regulation has attracted persons from.a wide variety of backgrounds including: medical researchers in reproductive physiology, biochemists, and physicians in obstetrical and gynecological practice who focus on a variety of repro- ductive functions and issues such as infertility, ovulation detection and improved conception regulation methods. In addition, the topic has attracted the interest of population researchers, governmental family planning agencies, nurses, marriage counsellors, priests and ministers, psychologists, philosophers and, most of all, married couples who are seeking alternative conception regulation methods to artificial and sur- gical procedures. The impetus to explore the relationship between self-esteem and conception regulation, in particular natural methods of conception regu- lation, as they pertain to the marital relationship, arose from: 1) personal contact with many persons who are involved in the professions cited; 2) a study of the writings on this topic; and 3) contact with numerous married couples who are using such methods. The body of liter- ature being generated by those interested in the topic of natural methods 2 has for the most part focused on the medical aspects of ovulation and fer- tility, and on the effectiveness of various natural methods to regulate- conception. The scientific studies completed to date are generally lim- ited to the effectiveness of natural methods and the superiority of one method over another in assisting couples in planning their families. In addition to the scientific studies, a number of books and articles have been published which discuss the nature and meaning of natural methods. Almost all of these latter writings contain references and statements to the effect that the use of natural methods of conception regulation has a positive effect on personal self-esteem.and on marital satisfaction. The available literature proposes that when a couple uses natural methods, after proper instruction and with personal motivation, the inti- mate area of physical sexual expression and behavior is more positively enhanced and has a supplemental effect on the whole of the marital rela- tionship. With the exception of the study by MtCusker (1976) no empir- ical investigation has been conducted to test the hypothesis that the use of natural methods within the marital relationship has such a positive effect. McCusker, using an open ended questionnaire as her research inr strument, found that 83 percent of her sample cf 98 couples reported pos- itive influence in their marital relationship through the use of natural methods. In her summary and recommendation for further research she states that the marriage building potential of the use of natural methods needs to be further explored. She suggests that further researCh be done on the relationship between the use of natural methods and personal self-esteem. Purpose and Objectives It is the purpose of this study to explore whether or not the use of natural methods of conception regulation indeed does have a positive effect on the personal self-esteem of married couples and on their mari- tal relationship. The major objective is to determine if there are any differences in the self-esteem levels between couples who use natural methods of conception regulation and those couples who use other methods of conception regulation. In addition, several secondary objectives are being pursued: 1. To test the assertion contained in the present literature on natural methods as to the positive benefits of using natural methods within the marital relationship. To determine the extent of married Catholic couples' knowledge concerning natural methods. To determine if Catholic couples who use natural methods evidence greater marital satisfaction than couples who use contraceptive or surgical methods of conception regulation. To gather information about Catholic couples and their conception regulation behaviors. Research Hypotheses Under Investigation Hypothesis #1: Catholic married couples who use natural methods of conception regulation will exhibit higher levels of self-esteem, as measured by the Tennessee Self Concept Scale, than will Catholic married couples who use other methods of conception regulation. Hypothesis #2: Catholic married couples who demonstrate different levels of marital satisfaction will differ in levels of self-esteem, as measured by the F-MA and the TSCS. Hypothesis #3: Catholic married couples who demonstrate different levels of marital satisfaction will differ in levels of self-esteem according to method of conception regulation used. Hypothesis #4: Among Catholic married couples who demonstrate high satisfaction in their marriages there will be differences in levels of self- esteem according to group and sex. The differences will be more evident for wives than for husbands. Assumptions: 1. That personal self-esteem is intimately involved with a couple's sense of marital satisfaction. 2. That natural methods of conception regulation have marriage and self-esteem building potential when accompanied by proper instruction and couple motivation. ' 3. The sample for this study, although a volunteer sample, is representative of middle class Catholic couples. 4. Marriages in which one spouse is non-Catholic (mixed marriage)- the assumption is made that the marriage itself is a Catholic marriage given the fact of a couple's membership in the popu- lation under study. 5 Conceptual Definition of Terms Natural methods of conception regulation: Natural methods are based upon the recognition of a man and a woman's fertility potential, and especially upon the identification of. the woman's fertile and infertile phases. The term "natural methods" is not to be confused with "rhythm". Rhythm as known and practiced was based on a rule of thumb calculation using a calendar approach which failed to take into consideration the irregularities of the menstrual cycle. The current literature on natural methods presently sees rhythm as a primitive state in the development of far more scientifically based natural methods. Medical knowledge of male and female reproductive phy- siology has advanced tremendously since the first "rhythm” method was developed by Ogino (1932) and Knaus (1933). Presently there are two major physiological bases upon which natural methods are founded. The first is the recognition of temperature shifts during a woman's menstrual cycle corresponding to the levels of estrogen and progesterone. The second is the observation of cervical mucus secretions which are recog— nized as a sign of the fertile phases of the menstrual cycle. There are three fully defined natural methods: 1) the basal body temperature method (BBT); 2) the Sympto-Thermic method (S-T); and 3) the Ovulation method based on mucus observation. Each has been sci- entifically researched and the literature and studies on these methods continues to grow. The Bibliography contains a special section on the scientific and biological aspects of natural methods of conception regu- lation. For the purposes of this study it is sufficient to know that such methods exist, that they have a scientific basis, and that with proper instruction a couple can use these methods to freely plan and space their children or to avoid a pregnancy. Contraceptive methods of conception regulation: For the purposes of this study all methods which seek to avoid or abort conception by means of chemical, mechanical, surgical or barrier methods shall be termed contraceptive. These methods include: the pill (all types), the intrauterine device (IUD), diaphragm, condom, foams, and jellies, withdrawal and sterilization. Sterilization, although a one time surgical procedure, is included in the category of contraceptive methods. As a barrier method, sterilization procedures block the natural functions of the human reproductive system by rendering them non- functional. Self-Esteem: Self-esteem as a concept is generally viewed as a conceptual com- ponent of the more inclusive process of self-conception. Since the writings of William James (1890) the concept of "self" has been studied at great length by numerous researchers. Rosenberg (1979) makes the point that, in spite of the abundance of research on self—concept and self-esteem, the term self, "stands as a concept foremost in the ranks of confusion," (Rosenberg 1979, p. 5). In light of its history the terms self-concept and consequently its component self-esteem are considered elusive terms lacking any universal definition (wells and Marwell 1976). Self-esteem generally refers to a person's attitude toward himself or herself. It is generally agreed that there are three aspects of this personal attitude: the cognitive, the affective, and the behavioral (Secord and Backman, 1964). Nathaniel Branden (1969) condenses these three into two inter related aspects. As Branden views it, self-esteem entails a sense of personal efficacy and a sense of personal worth. "It is the integrated sum of self-confidence and self-respect. It is the conviction that one is competent to live and worthy of living" (Branden 1969, p.110). Each person places some kind of estimate upon himself/herself as an object of value (Shibutani 1961). Much of what a person chooses to do, and the manner by which he/she does it, is presumed to be dependent upon his/her self-esteem. A person's evaluation or esteem of himself or herself "is the single most significant key to his behavior" (Branden 1969, p.110). In conventional clinical self-theories (neo-phenomenological), self-esteem, as it involves acceptance of self, and judgment of worth, involves the ability of a person to view himself/ herself honestly and to acknowledge his/her many shortcomings, and yet live happily and creatively with this awareness (McCandless 1961) - free of undue anxiety, self-criticism or defensive compensation (Wells and Marwell 1976). Overall, the evaluative, judgmental, and affective aspect of a person's self-conception involves the process commonly referred to as self-esteem. Marital Satisfaction: Marital satisfaction (happiness, adjustment, or success), like the term self-esteem, is beset with definitional problems. In the absence of any foundational theory giving rise to a uniform set of concepts the definitional problems in research on marital satisfaction are almost overwhelming. The research of the 1960's, as reviewed by Hicks and Platt (1970) strikingly bears this out. The term marital satisfaction is most frequently used to de- lineate the subjective state of the marital relationship in which an individual experiences a certain attainment of a goal or a desire. This subjective state includes the experience of mutual harmony, love, consideration, cooperation and satisfying communication between husband and wife. Beyond the marital dyad these same experiences as part of the total family relationShip pattern are considered to be influential on marital satisfaction (Imig 1971). Overview Chapter I has presented the problem under investigation, i.e., the proposed relationship between the use of natural methods of con- ception regulation and self-esteem within the context of the marital relationship, along with the study's purpose, objectives, hypotheses and conceptual definitions of terms. In Chapter II the pertinent literature dealing with the relationship of conception regulation methods, self-esteem.and marital satisfaction will be reviewed. The methodology of sampling procedure, sample characteristics, design and instrumenta- tion are discussed in Chapter III. In Chapter IV the results of the data analysis will be presented and summarized. A discussion of the study's results, focusing upon the strength of the relationship among the variables employed in the study are also contained in Chapter IV. The final chapter involves the conclusions, generalizations, and limitations of the study with suggestions for further research. CHAPTER II Review of the Related Literature Natural Methods of Conception Regulation: The literature on natural methods of conception regulation can be separated into several categories: 1) medical and physiological; 2) instructional manuals; 3) method and philOSOphy; 4) psychological factors. Prior to 1960 the majority of the literature was in categories 1 and 3. The writings produced were mainly authored by doctors special- izing in Obstetrics and Gynecology and by researchers in human physiology. It was not until the early 1960's that the scientific and medical know~ ledge accumulated before and during the 1940's and 1950's became trans- lated into practical teaching materials available to lay persons (Geller 1964; Voegtli 1966; Marshall 1965, 1970; Richards 1972; Thyma, 1970, 1973, 1978; Billings 1972, 1974; Kavanagh-Jazrauy 1975; McCarthy and Seli 1971; Kippley and Kippley 1975). As married couples' experience with the various natural methods grew, the psychological factors associated with using natural methods became more and more important and were considered more explicitly in the literature. Other than a very early study by Benedeck and Rubenstein (1942), the literature in the psychological area is only recent within the 1960's and 1970's. This review will only consider the literature which takes into account the psychological factors of natural methods as asso- ciated with marital satisfaction and self-esteem. With the exception of 10 McCusker (1976) and Bardwick (1973), the literature is of a non-scien- tific nature. John Harrington (1974) compiled a comprehensive review of the lit- erature on the psychology of family planning with particular reference to natural methods of conception regulation. Emphasizing those factors which might be determinants in the acceptance or rejection of natural methods, the first factor he mentions is personal self-esteem. How a person views himself/herself and his/her own worth must be taken into consideration when addressing the issue of family planning. His refer- ences concerning self-esteem cover the area of pregnancy, child birth, contraception and sterilization (Bibring 1959, Cohen 1966; Kroger 1959; Reik 1966, Rheingold 1964; Shereshefsky 1970; Twombly 1968; Wengraf 1953; and Westhoff, Herrera and Whelpton 1953). In his review, Harrington summarizes a composite picture of the per- son or couple having difficulties psychologically with family planning. They are usually: immature, dependent, self-punishing individuals who have a feeling of low self-esteem and self worth with little, if any, desire to control or have an over-all control over life. He adds that inabilities to assume responsibility, control impulses, appreciate long range goals and develop good sexual adjustment often characterize persons who have difficulties with family planning. Whatever the family planning method used, the studies reviewed by Harrington indicate that unless couples are able to understand and accept that there are advantages and disadvantages to a particular method of conception regulation, then either one or the other spouse may be demon- strating less than mature or stable attitudes. Hence there is a good chance that the marriage itself may be unstable (Harrington 1974). At 11 times various natural methods have been blamed for marriage problems given the requirement of abstinence associated with natural methods. However, it is doubtful that this fact alone is at the root of any par- ticular marriage failure. Perhaps at a deeper level there is a lack of maturity or even a lack of communication which has caused the marriage problem (Harrington 1974). This is particularly important to realize with reference to natural methods, for,"in some cases, the commitment to the marriage relationship may not be equal. Hence there may be the lack of commitment to mutual family planning." (Harrington 1974, p.11) Judith Bardwick (1972) addressed herself to the psychodynamics of contraception with particular reference to natural methods during an international conference on natural family planning. Noting the complex- ity of the issue of contraceptive behaviors she points out that: "Contraceptive, sexual and parental behaviors and responsibilities, and concepts of autonomy, self-esteem, are all germane" to the issue of the psychodynamics of contraception (Bardwick 1972, p.202). The dynamics of natural family planning favor a woman's self-esteem. Couples who use natural methods are usually acting jointly and this has a reassuring con— sequence for a woman of esteem from her partner and contributes to her feelings of worth (Bardwick 1972). From her studies on the psychology of women, Bardwick sees certain advantages to using natural methods. Use of a natural method can be reassuring and contribute to a feeling of com- petence when one remains in control of one's own body and control has not been relegated to a thing, i.e., a pill, IUD, diaphragm or condom. Since a great part of the identity and source of self-esteem for women relates to the reproductive system, it is an area in which the most powerful effect will be aroused (Bardwick 1972). 12 In addition to whatever fundamental differences may accrue from central nervous system differences in the sexes, the psychology of women is closely related to the physiological functioning of their reproductive system and their attitudes towards it. The reproductive system generates direct ef- fects upon the personality of women and psychological states will induce effects on the physiology of the system. Psycho- logically salient, the reproductive system will be perceived as a source of threat, as a source of satisfaction, as the crux of femininity. (Bardwick 1971, p.82) Seli (1975), Kippley and Kippley (1975), and Ball and Ball (1975) see natural methods of conception regulation as a way of life. This viewpoint and philosophy arises from seeing the need for sharing, mutual cooperation and improved communication in marriages which employ natural methods. This relational aspect so strongly emphasized in the natural family planning literature is strikingly absent when searching the lit- erature in regard to artificial contraception (Baar 1973). That the use of natural methods by married couples has marriage building potential is stressed by Kippley and Kippley (1975). Use of natural methods: involves mutual decision making; provides recurring op- portunities to think about the meaning of marriage, sex and spiritual values; addresses the issue of satiety with positive periodic abstinence; increases a wife's respect for her husband; and helps couples learn non- genital but sexual ways of showing marital affection (Kippley and Kippley 1975). Indeed it is a frequent comment from couples... that natural family planning demands a certain amount of maturity to begin with but results in an even more mature, stable and happy marital relationship. Repeatedly we have been told by others that the efforts involved in the NF? have been repaid tenfold in marriage enrichment (Kippley and Kippley 1975, p.184). McCusker (1976), in the only empirical study to date of couples' perceptions on the use of natural methods on their marital relationship, found that 82.9 percent of her sample (98 couples) reported positive 13 influence on their marital relationship using natural methods. Only 3 of the 250 responses indicated that there was little or no effect. Positive effects on the marriage were described in 176 responses, with increased communication and deepened love being most frequently mentioned. The complex and positive aspects of using natural methods as a way of total fertility awareness has been considered by Maloof (1977). However, he is cautious about his statements. The measure of marital satisfaction, as well as the effective- ness of a natural family planning method, is largely determined by attitudes towards abstinence. The marital relationship and personal growth are greatly enhanced by the practice of NFP when the difficulties of abstinence are acknowledged, so that the sacrifice involved may well be important and even essential for such growth (Maloof 1977, p. 301). Referencing his remarks, Maloof cites the work and thinking of Dr. Lidz. Lidz (1967)interviewed women over a period of a year who were using the P111 or IUD. She found that in women suffering from depression, the psychological roots of the depression often resulted from a frus~ tration over the interference with fertility. She drew the assumption that the "almost complete and certain frustration of a woman's sexuality, i.e. her procreative function, may well influence her general comfort, well-being, and self-esteem, and may lead to various symptoms, possibly culminating in depression" (Lidz 1967, p.761). Maloof comments that Dr. Lidz's observation in contraceptive women may prove by way of ne- gation that fertility must remain untampered with for a personal sense of fulfillment, for depression connotes the emotion of sadness at the loss of something of value (Maloof 1975). Many authors speak of the marriage building aspects of using natural methods. They would agree with Rendu and Rendu (1977) that the use of natural methods in conjugal love can become a positive force when lived 14 in tenderness, each spouse using his or her body intelligently to express love. Their thesis is based on tenderness, self-control, expressions in the spirit of giving for the mutual growth of each partner. The thesis of the present research focuses upon the question of whether or not the use of natural methods of conception regulation with- in the married relationship contributes to self-esteem. The literature and experiences of many couples support the exploration of this thesis. Related Literature on Contraceptive Behavior: Fawcett (1970), Marshall and Rowe (1970) have called attention to the dearth of studies of the psychologic aspects of contraceptive prac- tice. These authors point out that little attention has been given to the interpersonal factors operating between the spouses which affect con- traceptive practice. The majority of studies focus on the physiological effects of the oral contraceptive and the psychological reactions of males to vasectomy. In 1963 Ziegler, Rodgers and Altrocchi launched a longitudinal study on the psychological effects of male sterilization. They sought to measure the effects on self—esteem and marital satisfaction for both husbands and wives. Using a comparative design with 42 sterilized couples and 39 couples using oral contraceptives the 1965 findings indi- cated adverse changes in marital satisfaction up to two years after the vasectomy operation. All subjects were tested using the MMPI and the California Personality Inventory (CPI) before the vasectomy, one year later and four years later. Along with the administration of the test instruments, psychiatric interviews were conducted. Although the above mentioned researchers found that there was a high stated enthusiasm and satisfaction with the vasectomy after the 15 operation, there was a definite discrepancy between the test results and the subjects' reported satisfaction. This discrepancy may be explained in terms of cognitive dissonance reduction, i.e. an individual having taken an irrevocable step has a need to convince himself that what he has done was in his best interest (Ziegler, Rodgers, and Kriegsman 1966; Wolfers 1970). The follow up studies conducted by Ziegler et a1, one year later, showed increased psychological disturbances. The greatest degree of change occurred in marital satisfaction which was lower than pre-operative. Adverse changes in psychological adjustment were evident for as many as 50 percent of the subjects tested and followed up. These same men were rated significantly worse in overall adjustment by inter- viewing psychiatrists than were the husbands in the control group of pill users. However, these differences were not present four years ls- ter when both groups were re-tested and re-interviewed. This attenu- ation of adverse psychological reactions over time can be explained in terms of psychological compensation and the introduction of a Hawthorne effect due to repeated contact with the researchers. However, even after four years, many of the men studied exhibited some compensatory, stereotyped and exaggerated masculine behavior suggesting that vasectomy is reacted to by most subjects and their wives as if the operation had some demasculinizing potential (Ziegler et a1. 1969). Ziegler et a1 (1966) also reported on wife responses and test scores. Significantly more wives of husbands with vasectomies showed an increase in manifest anxiety symptoms on MMPI scale 7 (n=42, P- .05) than did wives using the pill. In addition, there were actually more negative changes in marital satisfaction for wives of sterilized husbands than for wives using the pill. These findings confirm, at least 16 tentatively, the suggestion made by Parker (1967) that adverse psycho- logical reactions may occur in the unsterilized marital partner. Ferber, Tietze and Lewit (1967) interviewed 73 men who had applied to the Association for Vbluntary Sterilization (AVS) for a vasectomy. One fourth to one half of the husbands reported improvement in relations with wives and over-all happiness in marriage. No objective measurements were used. In light of the findings of Ziegler, et a1, relative to the discrepancy between self-report and objective measurements the conclu- sions of Ferber et a1, can only be taken at face value. Wolfers (1970) found that in his sample a higher proportion of respondents stated that sexual inadequacy had led them to seek a vasec- tomy. Citing the findings of Ziegler and Rodgers (1966) he states that their tentative findings may indicate that submission to vasectomy may itself be indicative of personality disorder, and, in turn, lead to increased psychological disturbance. Accepting that vasectomy must invariably lead to some lowering of self-esteem, all men who have experienced it will require to adjust to a changed self-image in order to cope successfully with its psychological effects (Wolfers 1970, p.300). Kendall (1972) considered the relationship between vasectomy and self-esteem using the TSCS as his measuring instrument. He sought to determine whether a vasectomy operation would cause immediate significant changes in self-concept. He established three groups of subjects; those who were about to have a vasectomy; those who might consider a vasectomy in the future; and those who would not consider such an operation. He found that men who elect to and actually undergo a vasectomy have sig- nificantly lower positive self-concepts than men who would never consider having the operation. The vasectomy group scored lower on pre - post and follow up measures. 17 Research studies of women's reactions to tubal ligation have been less scientifically based, lacking objective measures. Many of the stu- dies have often been contaminated by psychiatric populations and con- comitant abortions (Schwyhart and Kutner 1973). These same authors reviewed 22 studies of women who received tubal ligations primarily for contraceptive reasons. The overall results of the studies yeild several conclusions. Women who have less than 3 children express greater regret over being sterilized (Paniagua, Taybeck and Janer 1964). Women with tendencies to project feelings of inadequacy or who have doubts of their own sexual control are not good candidates for sterilization (Parker 1967). The presence of marital problems and sterilization without the consent of spouse can lead to future problems (Norris 1964). Finally, women who have strong religious convictions, irrespective of church affiliation, or reservations expressed high regret (Norris 1964; Overstreet 1970). Many of the women studied demonstrated psychological problems such as depression and feelings of inferiority from impaired body image (Schwyhart and Kutner 1973). In summary, the research findings relative to male and female con- traceptive sterilization reveal that although there is a satisfaction with being sterilized, there is a price to be paid in psychological effects. The satisfaction comes more from having made a decision to do something about avoiding any future pregnancies than from having done something to enhance one's own self-development. 'The psychological effects seem more pronounced for men than for women, at least according to the present state of the research. It is interesting to note, however, that there can be psychological disturbances in the non-sterilized partner. 18 The Nature of Self-Esteem: An omnipresent factor of a person's psychology is his/her self- evaluation. The nature of this self-evaluation has profound effects on a person's thinking process, emotions, desires, values and goals. It is the single most significant key to a person's behavior (Branden 1969). Self-evaluation or a person's value judgment of his/her self-picture is commonly referred to as self-esteem. Although defined in various ways, self-esteem is indicative of the extent to which a person believes himself/herself to be capable, worthy, significant and successful. As a construct, self-esteem is seen as a conceptual component of the more inclusive process of self-conception (Wells and Marwell 1976). The related terms of self-esteem and self- concept are often used interchangeably. Investigators within the field of self-theory, such as Rogers (1951), Fitts (1965), Coopersmith (1967), Branden (1969), and Rosenberg (1979), use these terms to describe both the content (self-concept) and the feeling (self-esteem) of responses persons make about themselves. The self-concept is "an object of per- ception and reflection" (Rosenberg 1979, p.8). Self-esteem is the emo- tional response - how a person feels about himself/herself as an object viewed. Branden (1969) points out that self-esteem itself has two inter~ related aspects which entail a sense of personal efficacy and a sense of personal worth. "It is the integrated sum of self-confidence and self- respect. It is the conviction that one is competent to live and worthy of living" (Branden 1969, p.110). Meat definitions of self-esteem by self-theorists indicate that self-esteem is an attitude. wells and Marwell (1976) in their review of the self-esteem and self-concept literature organized the multitude of 19 descriptions of self-esteem into four basic types. Three of these refer to self-esteem as involving the notion of attitude. Specifically as an attitude, self-esteem involves the disapproval or approval of self (Allport 1937; Rosenberg 1965, 1979; Coopersmith 1967; Gergen 1971). The second type of self-esteem description involves the relation between attitudes or "selves", i.e. the real and ideal self (James 1890; Cohen 1959). The third type refers to a person's psychological responses, the feelings a person has about his/her self attitudes, i.e. self-' acceptance (Rogers 1950; Berger 1955). Branden (1969) delineates three basic conditions fundamental to the achieving and maintaining of self-esteem: 1) an indomitable will to un- derstand; 2) learning to live with and understand one's own emotions; 3) a profound respect for facts. Since these conditions are germane to the research hypothesis under investigation, a brief description of each follows. In Chapter IV these conditions will be referred to as they relate to the behavior of conception regulation. Branden states that the indomitable will to understand involves a desire for clarity, for comprehension, i.e. a person wants to clearly understand what is going on around him/her and how he/she fits into society. The process involves the drive of looking for and thinking in terms of principles as the indispensable means of cognitive clarity. The condition of learning to live with and understand one's own emotions is linked by Branden with self-regulation, whereby a person maintains cer- tian control over his/her existence. When feelings are not integrated within some rational process, a person can lose the sense of self- regulation which is essential to self-esteem. The third condition, a profound respect for facts, involves what is true or false, right or 20 wrong. Developing an ability to choose, judge and act independently of others strengthens a person's self-esteem. These conditions are reflected in the research on self-esteem (Coopersmith 1967). Persons with high self-esteem have confidence in their perceptions and judgments. Favorable self-attitude leads them to accept their own opinions and place credence and trust in their actions and conclusion. The trust in self which accompanies feelings of wor- thiness is likely to provide the conviction that one is correct and the courage to express those convictions. This, in turn, helps persons ex- press opinions and act according to their convictions even when they know these opinions and actions may meet with negative reception. On the other hand, persons with low self-esteem lack trust in themselves and are apprehensive about expressing unpopular or unusual ideas. A marked self- consciousness and preoccupation with inner problems contributes to the low self-esteem. The results of Coopersmith's research indicate that individuals who differ in self-esteem behave in markedly different ways. He notes that the behavioral differences are due to differences of anticipation re- action and willingness to trust and rely upon personal judgment as the basis for action. Marital Satisfaction: Rollins and Feldman (1974) noted that when considering the concept of marital satisfaction those variables which are of importance through- out the marriage relationship or at least a major portion of it, need to be considered. Since it is probable that couples are fertile during some 20-25 years of their married lives it seems that the variable of method of conception regulation needs to be added to the list of 21 variables usually considered. These include: age, employment, husband's prestige, variance over life-cycle, children,role performance and simi- larity of social background (Chadwick, Albrecht and Kunz 1976). The issue of reproductive fertility, in addition, spans that portion of the family life cycle, i.e. the years of raising and launching children, which is often seen as declining or fluctuating in marital satisfaction (Chadwick, et a1, Rollins and Feldman 1970; Burr 1970; Blood and Wolfe 1960). With the exception of McCusker (1976) this author is unaware of any specific studies which provide any correlational data between mari- tal satisfaction and methods of conception regulation used by married couples. McCusker in a non-comparative study found that couples using natural methods of conception regulation reported a positive influence on their marriage relationship -- eighty-three percent reporting positive influence. Research which considers spouse self-concepts related to marital satisfaction is far more evident. In a study of 70 volunteer couples, Cohn (1975) found that self-concept, based on self-scores and role per- ceptions, is related to marital satisfaction. Luckey (1960) reported an investigation comparing satisfied and unsatisfied marriages, based on the results of scores obtained on the Modification of the Marital Scales suggested by Locke (1951). She found that the congruence of the wife's perception of her husband and his own self-perception is significantly related to satisfactory marriages. However, the congruence of the hus— band's perception of his wife with the wife's perception of herself is not associated with satisfaction in marriage. Her results have since been substantiated by the findings of later research which report that 22 the husband's perception of self and the wife's perception of the husband are more significant for marital satisfaction (Stuckert 1963; Kotlar 1965; Taylor 1967; and Katz, Goldstein, Cohen and Stucker 1963). Blood and Wolfe (1960) found evidence that the husband's instrumental role is important to marital happiness. When a husband has a positive self- image of himself and this is reinforced by the wife's perception of him, there is evidence of higher satisfaction in the marriage. This consis- tent finding is further upheld by a questionnaire study by Aller (1962). She found that too great a capacity for independent thinking and too much aggression, self-centeredness or dominance in wives threatened the self-concept of husbands and marital patterns were affected adversely. Contrary conclusions were reached by Kringle (1976) who found that the degree of congruency for satisfied married couples was between the wife's self-perception and the husband's perception of her. The conclusions reached by the above studies find somewhat of a substantiation in the light of the WOmen's Liberation Movement of the 1970's. The dynamic of this movement and the growing role that women are playing within society has released within women behaviors of greater assertiveness, aggression and self-centeredness. The rising divorce rate and growing dissatisfaction with marriage may indeed be related to the behaviors mentioned by Aller (1962). This author's own counseling ex- perience, to a degree, upholds Aller's conclusions. When wives grow in an awareness of their unique womanhood and ability, and become more asser- tive in wanting to meet their needs and accomplish some personal goals, husbands feel threatened. The result is that the congruent feelings with the relationship, which were present within a more traditional role struc- ture become strained, lessening the general sense of satisfaction with the 23 marriage relationship. The husband no longer feels esteemed by his wife, and may even develop a sense of powerlessness and loss of confidence in meeting this new situation. The research of the 1960's was conducted within a very different social and role expectation context. It is evident, at least to this author, that further research needs to be developed which takes into consideration the role developmental changes realized during the most recent decade. As husbands face the task of re-evaluating their own self-concepts and adjust to new perceptions of them by their wives, there remains open the possibility for a renewed congruence which is no longer based on traditional or stereotypical patterns of marital relationships. The content and findings contained in the literature on natural family planning may very well indicate at least one way of handling the problems of incongruency in self-concept within the marital relationship. Faced with the reality of their own unique sexuality and fertility capa- cities beyond physical reproduction, a couple using natural methods with positive motivation can grow in a mutual appreciation and esteem for one another. This dynamic, often mentioned in the natural methods litera- ture, can serve to increase the feelings of worth for both spouses, hopefully resulting in a greater sense of marital satisfaction. CHAPTER III Methodologygand Design of the Study Introduction: Chapter 3 focuses on the methodology followed for the collection of the data in this study. Descriptions of the population, the sample, the sampling procedures, research design, and the instruments employed for measurement of the dependent variable, self-esteem, and the strati- fying independent variable, marital satisfaction, are contained within this chapter. An important aspect of this chapter is the section on specific problems encountered in the sampling procedure. Also presented in the chapter are the hypotheses to be tested and the operational defi- nitions of importance for the design. The Sample Definition of the Population: The population from which the sample was drawn for this study con- sisted of 750 married couples, who were parishioners of a particular Lansing Catholic parish and 13 other couples known to be using natural methods of conception regulation. The nature of the research demanded that only presently married couples be acceptable as potential partici- pants. Single parent families or recently divorced persons were excluded. In addition, only those couples who were still in their major child bearing years were included. These couples would likely be concerned with conception regulation methods as part of their family planning. 24 25 A Catholic population was chosen because the current state of mar- ried and family life is of vital interest to the Catholic Church. Also, this researcher has a personal concern with the conception regulation behavior of Catholic couples in light of the Catholic Church's moral teachings on contraception and conception regulation. Description of the Subjects: Husband's ages ranged from 22-49 years with a mean of 34. Wive's ages ranged from 21-45 with a mean age of 33 years. The number of years married ranged from 1-25 with a mean of 10.5 years of marriage. It was assumed that the vast majority of the subjects would be college educated. This assumption was based on the author's general knowledge of the parish membership and the geographical proximity of the parish to Michigan State university. A summary of the educational levels is given in Table 3.1. Seventy-five percent of husbands had completed some college or had attained advanced degrees. For the wives in the sample, the percentage of those having attended or completed college was 62.2 percent. TABLE 3.1 Educational Level Achieved for All Subjects (Percentages for Husbands and Wives) Educational Level Husbands Wives n=90 High School 24.5 37.8 Some College 17.7 26.7 College Graduate 31.2 24.5 Graduate School 26.6 11.1 Couples were requested to provide information as to their joint family income. The results, as tabulated in Table 3.2 indicate that the sample couples are in a middle income range with a mean income of $19,000. 26 TABLE 3.2 Joint Income for All Couples Joint Income Category Number of Couples n=45 ($10,000 1 $10,000-$15,000 7 $15,000-$20,000 14 $20,000—$25,000 15 >$25,000 8 Couples provided information on the number of children they pre- sently have, and on their desired family size. Number of children ranged from 0-7 with a mean of 2.5 children per family and a mode of 2 children. Four couples had no children. For all couples the mean for desired family size was three children. Actual and desired family size information is contained in Table 3.3. Couples using natural methods desired, on the average, a family size of four children. TABLE 3.3 Actual and Desired Family Size According to Group Method Group A (MGa) Method Group B (MGb) Actual Desired Actual Desired ii-z 35-4 i=2 i=3 n=15 n=30 Since methods of conception regulation are considered in this study to be a major variable, the types of method used by couples in both groups are included in Table 3.4 to further characterize this sample. 27 TABLE 3.4 Methods of Conception Regulation Used by Couples (Percentages by total sample and group) Method Group A (MGa) Method Group B (MGb) Method Total Group, Method Total Group Calendar Rhythm 2.2 6.7 Sterilization 23.3 36.6 Temperature 2.2 6.7 Vasectomy 26.6 39.9* Sympto-Thermic 21.1 63.3 Tubal Ligation 13.3 Combination 7.8 23.3 Pill 6.7 10.2 Diaphragm 11.1 17.0 “=45 “‘15 Condom 5.6 8.5 Condom‘with foams and jellies 5.5 8.5 Withdrawal 5.5 8.5 Abstinence 3.3 5.1 No method 4.4 6.8 n = 45 n=30 *Difference in percentages of 36.6 and 39.9 for sterilization method due to the occurrence of both spouses in same family being sterilized. The question is raised as to whether the sample of Catholic couples in this study differs in conception regulation behaviors with regard to the national population. A comparison table (Table 3.5) is provided using 33 of the 45 couples for this comparative purpose. The 33 couples included here represent those initial couples who responded to partici- pation in the study. The 12 of the 45 couples using natural methods are excluded in this comparative table. Selection Procedure: Subjects were selected on the basis of a couple's membership in the Lansing Catholic parish of interest, or on a couple's present use of natu- ral methods of conception regulation. This procedure resulted in the sit« uation that not all of the subjects were members of the parish population. Twelve of the 45 couples lived outside the geographical area of the parish. 28 TABLE 3.5 Methods of Conception Regulation Used - Comparison of Present Sample and a National Sample (figures in percents) Method National* Present Sample NC (n=1,938) C (n=679) C (n=33) Pill 34.3 34.2 9.0 IUD 9.0 r 7.6 - - Sterilization 33.1 26.0 33.3 Diaphragm 4.1 3.5 15.1 Condom 9.6 14.9 15.1 Withdrawal 1.8 2.4 9.0 Rhythm 1.7 5.9 9.0 Foam 3.9 2.6 --- Douche .5 3 Abstinence --- -- 3.0 Other or no method 2.0 2.6 6.0 NC = Non—Catholic C = Catholic *Source: 1975 National Fertility Study, coédirected by Norman B. Ryder and Dr. westoff under contract with Center for Population Research of the National Institute of Child and Human Development, DHEW; In Family Planning Perspectives, 1977, Vol. 9, p.204. Selection was also made on the variable of age, using the husband's age as the determining factor. The age range decided upon was 20—48 years. This age range was decided upon so as to include the largest number of couples still in their child bearing years. Sampling Procedure; Two methods of sampling were employed. The first involved the use of the facilities of the parish's computer listing of its parish population of 1300 families. A program was executed which selected out all married couples between the ages of 20 and 48, the husband's age being the variable chosen. The procedure resulted in a selection sample of 750 couples. The list of 750 couples was subjected to a random sam- pling procedure, using the Table of Random Numbers, without replacement by which a sample of 300 couples were designated for inclusion in the 29 study. It was to these 300 couples that a letter and consent form were sent explaining the nature of the study and inviting them to participate. (Letter and Consent Form -- Appendix A and B) In order to ensure that the total sample would include couples who used natural methods of conception regulation a second procedure was used. A volunteer group of 12 couples was obtained through the assis- tance of a couple who are teachers of natural methods. This second pro- cedure became necessary when it was discovered half way through the data collection procedure that only three couples in the responding sample were using natural methods of conception regulation. This low number endangered the comparative nature of the study and a testing of the re- search questions. This decision obviously had some consequences as to sampling methodology, and generalizability of the results. The total sample is treated as a volunteer sample thus reducing the generaliza- bility of the study to those couples in the study and to populations of Catholic couples with the same characteristics. Data Collection Procedure: All potential participants (n=312) were sent a letter explaining the general nature of the study and outlining what their involvement would entail. Along with this letter a Consent Form was sent. The re- turn of a signed consent form indicated willingness to participate in the study and complete all materials subsequently sent to them. On the receipt of the Consent Form, each couple was mailed, for completion, a Personal Information Form (Appendix C) and two capies of the Tennessee Self Concept Scale. When these were returned, a second letter and mailing were sent. The second mailing included two copies of the Family and Marital Adjustment Instrument and two copies of either Form A or 30 Form B of the Family Planning Questionnaire (Appendix D,E,F). All instru- ments were to be filled out individually by husband and wife. Because of the time factor, the volunteer couples (n=12) added to the study were given the entire package of letters, instructions, and test instruments and were directed to follow the same instructions and sequence for completing the materials as followed by all other partici- pants. This second procedure with the volunteers, although done for the convenience of the researcher, represented a break in methodology by not assuring sequence of response to research instruments. No controls were possible with either group to insure the absence of collusion. RespondipgpSample: Of the 300 potential participants who received the letter inviting them to participate only 54 couples decided to enter the study. This represents a return rate of 18 percent. The initial letter had reques- ted that a couple indicate their reasons if they decided not to parti- cipate. A self-addressed stamped envelope was provided to facilitate this possibility. Only four responses from the 246 non-respondents vol- unteered such information. Two respondents reported back that they had recently been divorced, thus excluding them from the study. One wife wrote saying that her husband refused to participate although she was quite willing, and one husband responded in a similar fashion. An attempt was made by mail to increase the response rate. Post cards were mailed to non-respondents. This action produced no further response of any type. During the extent of the data collection a significant mortality was realized. Twelve couples failed to return the first mailing which included the Personal Information Form and the TSCS. An additional 12 31 couples who returned the first mailing completed, failed to return the second mailing which contained the F-MA and FPQ. No reasons were received for dropping out of the study. Reminders were sent to these couples with the hope they would reconsider. No responses were received. Couples were informed at the outset of the study that they had the free- dom to discontinue their participation for whatever reasons they had decided upon. Specific Problems of Sampling Procedure and Methodology Affecting the Research Design: As noted earlier a volunteer group of 12 couples were added to the study in order to make possible the comparative nature of the research. Without these couples the study itself was in jeopardy. Since these couples constituted the majority (12 of 15 couples in Group A, who used natural methods), it was recognized that they clearly constituted a se- lection bias. The results and findings of this study must be interpreted in the context of this selection bias. As will be discussed in Chapter 4, the 12 couples included in MIGa selected for this study have certain characteristics which set them apart from the remaining couples in the study, the principal characteristic being that two-thirds of these couples (n89) have participated in an educational process for the learning of a natural method sometime prior to the actual study. This educational process must be viewed as an important variable influencing the self-esteem of these couples. The educational process in learning a natural method has a built-in dynamic for bringing about a greater awareness on the part of husbands and wives of their sexual identity. The interaction with other couples during the educational process, the mutual support given to one another, and the confidence in self resulting from such a process, further characterizes these couples. Therefore, it 32 is recognized that these couples have undergone a particular type of "treatment", uncontrolled for in the design, and which differentiates them from the remaining couples in the study's sample. Upon analysis of the demographic information these couples did not differ in any manner from other couples in the study. These couples were included at all stages in the analysis procedure. Other than the manner by which these couples were selected, and the already mentioned group characteristics, they were treated in the same way as the remaining 33 couples in the study. A final sample of 45 couples was settled upon prior to any analysis. Because of the low response rate (45 out of 312) the entire sample was designated and treated as a volunteer sample. This determination is based on the assumption that those couples willing to participate repre- sented a volunteer response. The low response rate also occasioned a change in the research design. At the outset of the proposed design, the design included two dependent variables: self-esteem and marital satis- faction. Prior to analysis of the data the assumption was made that only couples who considered themselves to have a good marriage decided to par- ticipate. The design was adjusted to designate marital satisfaction as a nuisance variable, treating it as an independent variable in the design. However, the data obtained from the results of the F-MA will be reported in the data analysis in order to test this assumption. The Research Desigp The dependent variable in this study was self-esteem as determined by the Total Positive Score on the Tennessee Self Concept Scale. The independent variables are marital satisfaction as measured by the F-MA and method of conception regulation, the latter contains two levels: 33 natural methods of conception regulation and artificial/surgical methods of conception regulation. Descrippion of Instruments Tennessee Self Concept Scale (TSCS): Developed by William H. Fitts (1965) the Tennessee Self Concept Scale consists of 100 self-descriptive items, of which 90 assess the self-concept producing an overall self-esteem score, and 10 assess self- criticism. The 10 self-criticism items are derived from the MMPI Lie Scale. The scale is self-administered and can be used with a variety of subjects 12 years and older. The respondent is asked to complete the 100 items by choosing one of five response options labeled from "completely false" or "1" to "completely true" or "5". The single most important score derived from the 100 test items is the Total Positive Score which reflects the overall level of self-esteem. This score is broken down into various aspects of self: Identity, Self- Satisfaction, and Behavior which represent an internal frame of reference; and Physical Self, Moral-Ethical Self, Personal Self, Family Self and Social Self, representing an external frame of reference. In addition to the overall level of self-esteem (Total Positive Score), the TSCS yields major additional scores: Variability Scores reflecting the amount of con- sistency from one area of self description to another; Distribution Scores, a measure of the individual definiteness or certainty when describing one- self; True-False Ratio, a measure of response style; Net Conflict Score, reflecting responses to positive and negative items. The TSCS also yields seven empirical scales for group discrimination of various sorts. These scales are: Defensive Positive, General Maladjustment, Psychosis, Personality Disorder, Neurosis, Personality Integration and Number of 34 Deviant Signs score. The norms of the TSCS were developed using a broad sample of people from various geographical locations, with age ranges from 12 to 68 years, males and females, mixed races and all levels of socio-economic strata. The test-retest reliability coefficient of the TSCS is reported as .83 (Fitts, 1965). Familypand Marital Adjustment Instrument (F-MA): The Family and Marital Adjustment Instrument is a 57 item instru- ment measuring family and marital satisfaction and has been adapted from Van der Veen's Family Concept Inventory (FCI). The FCI was originally constructed as a Q-Sort consisting of 80 true-false items, 48 of which entered into the scoring. Van der Veen et a1 (1964) reported signifi- cantly different mean scores for well-adjusted and maladjusted families (35.2 and 27.9 respectively; N830). Correlations between the FCI and the LockAWallace Scales have been reported by Van der Veen et a1 (1964), r=.67 with N-40 and by Hofman (1966) r372. Palonen (1966) developed a five choice form of the FCI, strongly agree to strongly disagree, using the significant 48 items found in the original Q-Sort. The subject were asked to respond to each item using one of five possible choices, after which a weight of 0-4 was assigned to each response. Imig (1971) devel— oped the FCI further using Hofman's five choice form. Using the signifi- cant 48 items which were used in the scoring of the FCI, he added 9 dummy variables, taking these from the original Q-Sort of 80 items. His study, Nal8l, consisted of married university students. He reported mean scores for husbands and wives ranging from 133.6 to 144.5. Hofman's (1969) research comparing clinical and non-clinical families reported means for the FCI (N815) quite different from Imig. The mean score for clinical families ranged from 123.8 to 126 and for non-clinical families 153.1 to 156.1. 35 The present FMA instrument used in this study is the version of the FCI as developed by Imig (1971). It was chosen because of its simplicity and relative brevity. In addition, it allows the respondent greater free- dom of answers than the original T-F design. Since the scope of this stu- dy revolves around the issue of family planning, this instrument lends it- self to a fuller understanding of the response scores than other marital satisfaction or adjustment instruments. It purports to measure not only marital adjustment but also family adjustment. The items on this inven- tory are less direct and thus appear to be less threatening. Family Planning Questionnaire (FPQ): The Family Planning Questionnaire is a researcher developed instru- ment for this particular study. It has two forms, Form A and Form B (Appendix E and F). Form A was completed by those couples who indicated in their initial response of participation that they were currently using a natural method of conception regulation. Form B was completed by all other couples regardless of method of conception regulation being used. Prior to the finalization of the FPQ instrument a volunteer sample of 9 couples (n818) completed and offered feedback and evaluation on the original single form FPQ. This original form was also sent to four inde- pendent reviewers with varying degrees of experience with family planning (in particular natural methods of conception regulation). The sugges- tions and recommendations of these two groups were weighed and incorpo- rated into the present instrument. This review of the instrument resul- ted in a decision to have two forms. The reasons for this decision were: 1) the original was too long, 58 questions; 2) it was complicated in that it required too many choices and exceptions depending on which methods of conception regulation were used. Both forms of the questionnaire have 36 both identical and similar type questions for purposes of comparison. Final analysis compares only identical questions. The FPQ does not aim at measuring any particular variable or atti- tude. It was developed as a survey type questionnaire to elicit from the responding couples, information relative to the conception regulation practices, their general satisfaction and dissatisfaction with such meth- ods, and their general feelings and attitudes about any effects of such methods on their marital relationship. Two sexual behavior items (Form A, qq 23—24 and Form B, qq 25-26) were asked to gain some knowledge of the dynamics of a couple's sex relationship. The FPQ was designed with the purpose that some comparisons and relational statements could be made between the FMA overall score and the satisfaction questions in the FPQ. Since these questions also relate to basic concepts of self it would give another perspective on the overall self-esteem score. Statistical Hypotheses Statistical Model for N Way Anova: iijk = if...+o<1 + Bj + (own) + («Byijw +e ° t, 1.76, p (.05 level. A similar "t" test was computed for the husbands' mean self-esteem scores, also with an alpha level of .07. No significant differences were found, as would be expected from the data contained in the table of mean scores (Table 4.3). The percentage of husbands and wives with high FéMA scores is significantly different for both groups. Reasons were sought for the significant difference among wives through an examination of the raw data scores on both self-esteem and marital satisfaction among wives in MGb. It was discovered that those 43 TABLE 4.3 Self-esteem Mean Scores for Husbands and Wives with High Marital Satisfaction (n=3l) Self-esteem MGa MGb n Husbands Wives Husbands Wives I: 376 383 372 364 Percent 46.6 60.0 16.6 33.3 Number of Subjects 7 9 5 10 31 wives who were sterilized or who were married to a husband with a vasec- tomy had a disproportionate number of low scores on the TSCS. In order to test the significance of this finding the wives within MGb with high marital satisfaction scores and who were either sterilized or married to a sterilized husband were excluded from an additional post-hoc test. The alpha level for this third "t" test was set at .08. This additional test was computed to test a working hypothesis that it was this group of wives who were responsible for the significant differences found between couples with high marital satisfaction. This procedure resulted in excluding two subjects from MGb users, leaving 8 wives to be included in the new calculation of mean scores on self-esteem. A new mean of 372 was computed for wives within MGb. A post-hoc test of means with an alpha of .08 was computed. The test sta- tistic for "t"¢x.05 with 9 degrees of freedom is l.83,higher than the calculated "t" of 1.08. Therefore, it was concluded that there is no difference in self-esteem scores at the .08 level between wives who use natural methods and wives who are not sterilized or married to sterilized husbands. It was further concluded that those wives in MGb who are 44 sterilized or married to sterilized husbands and who have high marital satisfaction scores did indeed shift the mean score for wives in MGb to produce the prior significance found between wives. Results of the FéMA: The scores obtained for all couples on the FAMA ranged from a low of 50 to a high of 180. The mean score for all couples is 131.6 with a standard deviation (S.D.) of 27.2. High scores for all couples range from 146-180, medium scores range from 133-145 and low scores range from 50-132. Table 4.4 illustrates the mean F-MA scores by method group and sex of subjects. TABLE 4.4 Mean F-MA Scores for Husbands and Wives MG a MC}, n Husbands Wives Husbands Wives FMeA Mean Score 143.4 140.1 119.5 133.6 Group Mean 141.7 126.5 Number of Subjects 15 15 3O 30 90 Upon examination of the results in Table 4.4 it can readily be seen that MGa couples scored higher by 15 points on the FéMA. Higher scores were true for both husbands and wives in M68. No statistical tests of significance were calculated for the F-MA results since scores were used to stratify subjects on self-esteem measurement. Table 4.5 compares the results on the FAMA for these couples with the results obtained by Hofman (1969) and Imig (1971). The study by Hofman differs in that his subjects were separated into clinical and non- clinical groups. The mean score obtained by husbands in this study is 45 TABLE 4.5 Comparison of Mean F-MA Scores Clinical Non-Clinical Hofman Average 126.0 154.6 Husbands 128.3 153.1 Wives 123.8 156.1 Imig Average 140.3 Husbands 137.9 Wives 142.9 This Study M Average 133.7 Husbands 131.0 Wives 136.5 closer to the clinical mean than it is to the non-clinical mean score for husbands obtained by Hofman (1969). Couples in MGa (cf. Table 4.4) come closer to the score results obtained by Imig (1971). The results on the FAMA as presented in Table 4.6 contain some in- teresting findings. A disproportionate number of husbands (n-l9, 63.3 percent) within MGb have extremely low FAMA scores. Of those husbands TABLE 4.6 Mean F-MA Scores for Husbands and Wives (Means and Percentages) F-MA Level MGa MCb n Husbands Wives Husbandsl Wives High 157.1 156.7 156.6 159.6 (47.0) (60.0) (16.6) (33.3) 31 Medium 139.8 -—-- 137.3 140.1 (33.3) ----- (20.1) 30.0) 20 Low 118.6 116.0 104.4 103.0 (20.0) (40.0) (63.3) (36.6) 39 Number of Subjects 15 15 30 30 90 46- represented in this low range, 42.1 percent (n-8) have had a vasectomy or are married to a sterilized wife. Fifty-four percent of the wives within MGb (n-6) who have low marital satisfaction scores are either sterilized or married to a husband who has had a vasectomy. The distribution of high, medium and low scores for couples within MGa presents a quite differ- ent picture. The majority of husbands and wives in MGa achieved high scores on the F-MA. The interesting feature for these couples within Table 4.6 is that the wives scored either high or low. There are no wives with scores in the medium range. This may indicate a lack of ambivalence about marital satisfaction on their part. Content Analysis of the FPQ: It was the original intent that the Family Planning Questionnaire (FPQ) would be used to gain some insights into the sexual and marital satisfaction of the participating couples beyond test scores. Additional- ly, the majority of questions sought to establish the present satisfaction level with the method of conception regulation being used. In order to help substantiate and support any differences found between MGa and MGb a categorical content analysis was performed on a certain set of questionnaire responses. The content analysis is limited to two categories of questions: 1) satisfaction with present method of conception regulation, and 2) questions relevant to marital and sexual satisfaction. The results of this analysis are presented in a series of tables which follow. Responses frequencies are represented in percentage figures. Table headings are summation statements of the actual questions. The overall analysis of the questionnaire responses for both groups found very little variance of response on those questions which asked about general satisfaction and agreement. However, certain responses to the 47 questions concerning sexual intercourse indicate some differences among couples. Where meaningful differences occur these will be commented upon in the text following the tables. Several questions were asked concerning satisfaction with the meth- od of conception regulation used and its effect on the marital relation- ship. Tables 4.7 through 4.13 contain the response frequencies to these questions. TABLE 4.7 Satisfaction with Method Used Response MGa MGb n Yes 76.6 78.3 No 3.3 15.0 Sometimes 13.3 --- No response 6.6 6.6 n=30 n=60 96 TABLE 4.8 Individual Confidence with Method Used Response MGa MGb n Husband Wife Husband Wife Absolutely confident 53.3 60.0 53.3 46.6 Confident, most of time 46.7 33.3 33.3 30.0 No Confidence ---- ---- 3.3 6.6 No Response ---- 6.6 6.6 13.3 n=15 n=15 n=30 n=30 9O 48 TABLE 4.9 Spouse Agreement on Method Used Response MGa MGb Husband Wife Husband Wife Yes 100.0 100.0 90.0 90.0 No --- ---- 6.6 6.6 No response ---- ----- 3.3 3.3 n=15 n-15 n=30 n=30 TABLE 4.10 Arguments about Method Used Response MGa MGb Husband Wife Husband Wife Often --- ---- ---- --- Once in a while 6.6 ---- 3.3 13.3 Seldom 26.6 6.6 16.6 16.6 Never 60.0 86.6 73.3 63.3 No response 6.8 6.8 6.8 6.8 n-15 n=15 n=30 n=30 90 TABLE 4.11 Method Helps Marital Communication Response MGa MGb Husband Wife Husband Wife Yes 80.0 80.0 56.6 66.7 No 20.0 20.0 40.0 30.0 No response ---- --— 3.3 3.3 n=15 n-15 n=30 n=30 90 49 TABLE 4.12 Issue of Conception Regulation Interferes with Marital Relationship Response MGa MGb n Husband Wife Husband Wife Often ---- --- ---- 3.3 Once in a while ---— 6.6 10.0 6.6 Seldom 26.6 6.6 13.3 16.6 Never 66.6 86.6 73.3 70.0 No response ---- ---- 3.3 3.3 n=15 n=15 n=30 n-30 90 TABLE 4.13 Present Practice of Conception Regulation Enhances Marital Relationship Response MGa MGb n Husband Wife Husband Wife Often 46.6 66.6 50.0 40.0 Once in a while 26.6 13.3 26.6 13.3 Seldom 6.6 ---- 16.6 30.0 Never ---- ---- 3.3 13.3 No response 20.0 20.0 3.3 3.3 ntlS n-15 n=30 n-30 90 A series of questions were asked of each spouse concerning their feelings about being refused sexual intercourse and about their own re- fusal of sexual intercourse. So that the following tables (4.14 through 4.21) may be more clearly understood the actual questions precede each set of tables, and the table headings indicate the various possible responses. 50 Question 23 or 25: If for any reason you do not wish to have sexual intercourse with your spouse, how is your refusal usually received? TABLE 4.14 With Understanding and Love Response MGa MGb n Husband Wife Husband Wife Often 93.3 86.6 26.6 46.6 Sometimes --- ---- 43.3 46.6 Never ---- --—- 16.6 ---- No response 6.6 13.3 13.3 6.6 n=15 n=15 n-30 n-30 90 TABLE 4.15 With Some Criticism and Negative Feelings Response MGa MGb n Husband Wife Husband Wife Often ---- ---- 3.3 10.0 Sometimes 6.6 13.3 50.0 36.6 Never 80.0 53.3 23.3 43.3 No response 13.3 33.3 23.3 10.0 n=15 n-15 n-30 n-30 90 TABLE 4.16 With Silent Resentment Response MGa MGb n Husband Wife Husband Wife Often ---- 6.6 10.0 10.0 Sometimes 33.3 20.0 30.0 36.6 Never 46.6 46.6 30.0 36.6 No response 20.0 26.6 23.3 16.6 n=15 n-15 n-30 n-30 90 51 Question 24 or 26: How do you feel about your own refusal to have sexual intercourse? TABLE 4.17 Frustrated Response MGa MGb n Husband Wife Husband Wife Often 6.6 --- 6.6 10.0 Sometimes 26.6 46.6 36.6 46.6 Never 53.3 13.3 26.6 30.0 No response 13.3 40.0 30.0 13.3 n=15 n=15 n=30 n-30 90 TABLE 4.18 At Peace Response MGa MGb n Husband Wife Husband ' Wife Often 53.3 46.6 20.0 E 20.0 Sometimes 20.0 20.0 30.0 ‘ 33.3 Never ---— 6.6 26.6 ; 33.3 No response 26.6 26.6 23.3 g 13.3 1 n=15 n=15 n330 n-30 90 TABLE 4.19 Misunderstood Response MGa MGb n Husband Wife Husband Wife Often --— --- 3.3 13.3 Sometimes 33.3 33.3 53.3 50.0 Never 40.0 40.0 13.3 26.6 No response 26.6 26.6 30.0 10.0 n-15 n=15 n=30 n=30 90 52 TABLE 4.20 Guilty Response MGa MGb n Husband Wife Husband Wife Often ---— 13.3 10.0 20.0 Sometimes 26.6 20.0 36.6 40.0 Never 46.6 33.3 26.6 30.0 No response 26.6 26.6 26.6 10.0 n=15 n=15 n-30 n-30 90 TABLE 4.21 Accepted and Loved Response MGa MGb n Husband Wife Husband Wife Often 73.3 73.3 30.0 43.3 Sometimes 13.3 6.6 50.0 40.0 Never ---- -- 6.6 10.0 No response 13.3 13.3 13.3 10.0 n=15 n=15 n-30 n=30 90 Couples were asked if the use of their present method of conception regulation helped them feel more positive about their marital relationship. As can be seen from the response frequencies in many of the pre- ceding tables there is a fluctuating variance between couples in their responses. Couples report general satisfaction with the particular meth- ods of conception regulation being used. Couples in MGb are more likely to express dissatisfaction and lack of confidence with their methods. Spouses generally agree on the method being used with the exception of a On the question about mari- few couples in MGb indicating no agreement. tal communication being helped by the use of a method, those couples 53 using natural methods respond with a higher frequency of positive respon- ses. With reference to the questions concerning sexual intercourse, couples in MGa evidenced higher response frequencies on the positive state- ments while the couples in MGb evidenced greater frequency of responses on the negative statements. Each form of the FPQ (A and B) contained a few open ended questions to allow subjects to express themselves more fully on the issue of con- ception regulation. The following summary considers these open ended ques— tions and the responses. Each group of couples will be considered separately. Couples - MGa: Questions 12 and 13 in FPQ-Form A asked couples to identify the greatest benefit and the greatest difficulty experienced in using a natu- ral method of conception regulation. There were 28 individual responses with 31 separate reasons for natural methods being beneficial. These have been categorized for reporting purposes. The most frequently stated benefit was peace of conscience, mind or body, accompanied by no guilt feelings about acting contrary to the teachings of the Catholic Church (n=10). Husbands reported that the greatest benefit for them was that the method was healthy for their wives (n84). Wives expressed the same benefit by indicating that using natural methods involved no harmful side effects and did not pollute their bodies with chemicals or other artificial mechanisms (n=5). The fact that the methods used are natural and do not interfere with normal body functions was mentioned by both husbands and wives (n=8). A few couples expressed that using natural methods brought about greater unity, sharing and coop- eration in their marriage (n84). As might be expected of couples in 54 this sample, using natural methods had spiritual benefits also. Five couples mentioned that by using a natural method they were being respon- sible to the natural design of God's ordering of the human body and its fertility potentials. One wife expressed the benefit that natural meth- ods were non-abortive. Only one husband stated that the greatest benefit for him was that using natural methods prevented pregnancy. This is, as might be expected, in marked contrast to husband responses in MGb. Couples using natural methods responded to Question 13 (greatest difficulty) with an almost unanimous response, a response which was very predictable. The greatest difficulty is abstinence (n=10). This is the response most often seen in the literature on natural methods (Marshall and Rowe 1970). But despite this difficulty the majority of couples who participated in the study by Marshall and Rowe were of the opinion that using a natural method helped their marriage (Marshall and Rowe 1970). Other difficulties expressed included: learning and understanding the temperature charts (n-12); the work and sacrifice involved; discipline of checking temperature and being faithful to applying the steps of the method (n=3). One wife expressed her greatest difficulty by saying that natural methods were so misunderstood by so many. Various questions provided subjects an opportunity to add "other" reasons for satisfaction and dissatisfaction with the methods used (questions 8, 9,10 and 20). The responses were few and are contained in Appendix G). Couples - MGb: Couples in MGb were asked the same questions relative to benefits and difficulties experienced with the methods of conception regulation being used (questions 21 and 22). The most frequently reported benefit about the various contraceptive methods used was that they prevent 55 pregnancy (n=l4). Those couples using the diaphragm reported the fact of no side effects and that the method was botherless. Only one respondent mentioned that the method used was healthy (diaphragm). One husband said that the method used (Pill) helped him and his wife plan for a family more effectively. Those couples responding to question 22 concerning difficulties with method of conception regulation fall into 3 categories. The most frequent response was that there were no difficulties (n=l3). This response was mentioned primarily by couples who had been sterilized. Another group of couples mentioned difficulty with the diaphragm saying it was bothersome and interfered with love making (n=2). Two couples expressed that they experienced guilt and inner conflict because the methods used were not sanctioned by the Catholic Church. One husband who uses no method hon- estly said it just doesn't work. A husband whose wife uses the pill said he had difficulty and concern over his wife's health. Questions 8,16 and 31 provided the couples in MGb with the opportu- nity to add comments to their answers. Question 16 dealt with those who have been sterilized, and asked if they would do it over again. Of those responding yes to having been sterilized, only four (of a possible 11) responded that they would do it over. One husband said he would not because the Church disapproves of sterilization. Question 31 asked about future changes in conception method. Only 3 responses were offered: 2 responded that they would be sterilized and one said that he and his wife would consider the pill or diaphragm. Only one wife added a comment to question 8 which asked about discontinuance of any previous method. She had discontinued the pill in order to become pregnant. 56 Summapy of Findipg_: The analysis of data supported, in part, the hypotheses under inves- tigation for this study. Catholic couples who use natural methods of con- ception regulation do demonstrate higher levels of self-esteem than do couples using other methods of conception regulation. This difference is true even when couples in both methods groups scored high on marital sat- isfaction. The differences in self-esteem scores are more pronounced for wives, a difference of 19 points, than for husbands. These differences suggest an interaction according to sex, method and marital satisfaction. It is evident from the analysis of the data that those couples who have been sterilized score lower on both self-esteem and marital satisfaction measures. Within the sterilized group, lower self-esteem is noted more often for wives, and lower marital satisfaction for husbands. The scores achieved by this group of couples are in line with the findings within the literature on sterilization which indicate lower self-esteem and marital satisfaction among sterilized couples. The test for an interaction between marital satisfaction and method used indicated no statistically significant results. However, this fin- ding is suspect given the statistical analysis used. The 2—Way ANOVA, with disproportionate cell frequencies, and nested factors, fails to take into account the total sources of variation. When actual cell means are examined wide variations are evident among couples with either high or low marital satisfaction. It was suspected then that interactions do exist. Post-hoc procedures for mean differences for husbands and wives with high marital satisfaction were computed. Differences proved sig- nificant for wives but not for husbands. This result leads to at least a tentative and partial conclusion concerning Hypotheses #3 and #4; 57 i.e. that interactions probably exist, and that wives, moreso than hus- bands, differ in self-esteem levels according to method of conception reg- ulation used. Results of the data analysis with a ZéWay ANOVA are pre- sented in Table 4.22. TABLE 4.22 Analysis Table of Statistical Hypotheses Statistical Hypotheses df Mean Squares F P Decision #1: Ho 0(1 = O 1 2280.2 2.669 .106 Reject #2: Ho $1 - 0 2 12005.0 14.051 .001 Reject #3: HON-EU = 0 2 499.5 .585 .560 Fail to Reject #4: Ho‘Y4ij= 0 Inspection of Cell Means Reject From the information obtained from the FPQ it was discovered that although couples were satisfied with their present method of conception regulation, couples using natural methods evidenced more positive res- ponses on agreement and communication. The greatest differences between method groups were on the questions dealing with sexual intercourse (cf Tables 4.14 through 4.21). Couples using natural methods reported positive responses more frequently, and couples using other methods more frequently reported negative responses. Couples using natural methods were more likely to respond that their refusals for intercourse were received with understanding and love, while among couples who use other methods, responses of criticism and negative feelings were more frequent. Couples who use natural methods report more often that they feel at peace, accepted and loved when they refuse sexual intercourse. Far fewer couples using other methods feel this way. Rather, many of them feel misunderstood and guilty. 58 Although couples using natural methods experience difficulties with abstinence, these difficulties do not appear to be detrimental to their self-esteem or sexual and marital satisfaction. Discussion of Results: The results of the study suggest a joint occurrence between being well adjusted in marriage, higher self-esteem and the use of natural methods of conception regulation. Further, that among couples with higher marital satisfaction those couples who use a natural method of conception regulation are statistically discernable from.well adjusted couples who do not use natural methods. This significance may have resulted from the presence within MGb of a large percentage (36.6) of sterilized couples. This group of couples (n=ll) demonstrated, by comparison with all couples, lower self-esteem and lower marital satisfaction scores on both instru- ments employed in this study. Because of the sampling problems discussed earlier, and the repre- sentativeness of a highly volunteer sample, no generalizable statements can be made directly. However, with reference to the literature on natu- ral methods and contraceptive behavior, there are indications that the results and differences between MGa and MGb are in accord with previous studies and writings, The natural methods literature is consistent and unanimous as to the positive benefits for the interpersonal dynamics of the marital relationship for couples using natural methods. Couples who use natural methods are usually acting jointly and this has reassuring consequences, especially for a woman of her esteem from her spouse (Bardwick 1973). Given the score results on self-esteem for husbands who use natural methods, Bardwick's thesis could be extended to men. The findings of this study are consistent with the literature on contraceptive 59 behavior relative to sterilization. In particular, this study underscores the negative psychological effects among husbands and wives using contra- ceptive or surgical means for conception regulation. Although significant differences were found between method groups, an important issue which has not been discussed thus far pertains to the strength of the association between the variables used in this study, i.e. method of conception regulation, self-esteem and marital satisfaction. A test of significance, (.02 , was computed to test the strength of the inde- pendent variables in association with self-esteem. The strength of asso- ciation for both variables was found to be quite low: 0.5 percent for methods and 1.4 percent for marital satisfaction. This results in a very weak association between the independent and dependent variables. Given this result alone it could be concluded that the differences in variance reported in the analysis are not due primarily to either method of con- ception regulation or to level of marital satisfaction. The lack of any significant strength of association between the variables could indicate: 1) the design did not take into consideration all the possible variables influencing self-esteem; 2) the analysis was inappropriate to the design; or 3) the measurements were not fully valid. The objective of the study was to discover if any differences do exist between groups of married couples depending on the method of con- ception regulation used. Differences were found as the results of the analysis indicate. This finding alone opens the way to further research with tighter controls for variance and possibly better research instruments. In Chapter V several variables which were overlooked or unaccounted for will be discussed. Within this present section two factors need to be mentioned to fill out the discussion of the results. Couples who use 60 natural methods of conception regulation are more likely to seek support from other couples who are also using such methods. They first encounter one another during the educational process of learning a natural method. From the personal experience of this researcher with a number of couples using natural methods, I have found that this factor of collegiality can be an important variable for success and satisfaction with a natural method. Such support and communication could also influence the self-confidence of couples using natural methods. Whether the couples in this study relate to other couples in this manner is beyond the knowledge of the researcher but nevertheless a valid assumption. Whatever the actual experience was for couples in this study, collegiality is an important aspect which should be taken into consideration in further research, for it may be the very social relationship environment within which a natural method is used which serves to help the marital relationship and effect self-esteem. The social relationship environment is a key aspect of other inter- active educational processes aimed at building self-esteem, such as Alcoholics Anonymous and Parents Anonymous. This fact gives support to the important influence of collegiality. Persons mutually involved in an area of interest can have a definite psychological impact on one another's selfdworth. In the interactive dynamic of persons reacting to one ano- ther's strengths and supporting one another through a learning and growth process, personal self-esteem can be enhanced and strengthened. The very principles underlying group dynamics and group process aim at building self-confidence or self-esteem. Mention has been made in the literature review on contraceptive be- havior of cognitive dissonance reduction as it pertains to sterilized couples. Given the Catholic Church teaching on contraception and 61 sterilization, and the response of MIGa couples that the Church's teaching influenced their decision for natural methods, it might be proposed that this factor could explain some of the difference between groups of couples. Those couples who are acting in agreement with Church teaching and suppor- ted in such behavior could have a good feeling about such agreement con- tributing to their self-esteem. On the other hand, couples not acting in agreement could be evidencing some underlying guilt. This preposition finds some support in the results for MGb between reported satisfaction in.marriage and actual test scores. If direct questions had been asked about self-esteem, would differences be evident between reported feelings of esteem and test scores? This question remains open for further consideration. An assumption was made relative to the sampling procedure that only couples who considered themselves to be well adjusted in marriage had chosen to participate in the study. Given the score results on the F-MA, and the frequency of low scores, this assumption can be confidently rejected. Couples who may judge themselves to be happily married may very well not be. The test results certainly indicate support for this proposition. Within the review of literature on self-esteem the basic conditions for self-esteem, as outlined by Branden (1969) were summarized. It was stated then that these conditions appeared relevant to the behavior of natural methods of conception regulation and would be discussed here in Chapter IV. Branden outlined three basic conditions fundamental to the achieving and maintaining of self esteem: 1) an indomitable will to understand; 2) learning to live with one's own emotions; 3) a profound respect for facts. 62 Indomitable Will to Understand: Implicit for the use of natural methods must be a will to understand the basic principles of reproductive physiology. This initial requirement can lead persons to greater self-knowledge. This dimension of self- knowledge is well developed by Ball and Ball (1975). As couples seek to understand their fertility and procreative power they begin to live in a deeper awareness of their body's environment. This growth in knowledge, for many couples, brings about a deeply spiritual recognition of the beauty of their bodies and the power and responsibilities they have in generating new life (Ball and Ball 1975). The same authors state that the use of natural methods involves a certain philosophy of life which "recognizes and values the procreative and the unitive dimensions of coital sexual intercourse as a dual reality" (Ball and Ball 1975, p.13). "The meaning of conjugal love and an under- standing of personhood and human sexuality cannot be separated from the fully human power of generating new life" (Ball and Ball 1975, p.313). Since husbands and wives are striving to know one another more deeply in love they face the task of understanding themselves as male and female persons. This involves understanding the principles of masculine and feminine as these are expressed within the person of both men and women. Both the feminine and masculine principle is essential to living creatively. ...The masculine seeks to reach out and create through a differentiation of life. The feminine seeks to receive and hold life together in a harmonious whole (Ball and Ball 1975, p.25 ) For motivated couples who seek and desire to understand the wholeness of each other, the dynamics involved with the use of natural methods of con- ception regulation can serve to strengthen self-esteem . 63 Learnipgpto Live with One's Own'EmOtions: Branden (1969) states that an important aspect of living with one's own emotions is self-regulation. Healthy self-regulation consists in "recognizing that emotions are effects - consequences of value-judgments- and 0f being concerned to know the nature of those judgments and the degree of their validity in a given context" (Branden 1969, p.118). The very choice by couples who use natural methods involves a value judgment about the meaning and nature of sexuality within the context of marriage. A judgment is made that contraceptive techniques are either unhealthy or immoral, and that natural methods are more in harmony with nature. Those couples who are religiously oriented probably judge that the use of natu- ral methods is in the plan of God. Like all decisions about conception regulation behavior, the decision and judgment for natural methods must take into consideration the wide range of sexual emotions. A couple using natural methods recognizes the emotions involved in their sexual energies and decides to regulate these within a rational process of peri- odic continence. Such self-regulation involves a definite and thought- ful approach to coital relations and other sexual expressions of love within marriage. A couple through their knowledge and awareness of the fertile and infertile phases of the menstrual cycle regulate their coital expressions of love-making. Ball and Ball (1975) in their discussion of periodic continence emphasize that coital relations assume their deepest meaning within the context of a married love relationship based on fidel- ity and trust. Citing Eric Fromm, this love is an art "which can be mastered only with self-imposed discipline, intense concentration and long patience" (Ball and Ball 1975, p.31). The use of natural methods can then help develop this art of loving because of the basic discipline, 64 concentration and patience involved. Branden states that self-regulation is "essential to self-esteem" (Branden, p.118). It seems quite appropriate then to conclude that when couples exercise a rational process of self-regulation over their sexual and genital emotions that their self-esteem can be served and enhanced. Profound Reppect for Facts: The final condition for self-esteem given by Branden involves an ability to choose, judge and act independently of others. This ability strengthens a person's self-esteem. The choice made by couples to use natural methods is definitely a choice made independently of what the majority of couples consider rational conception regulation behavior. Quite often couples make the decision for natural methods in the midst of contrary and critical judgments by others. Couples using natural methods are often ridiculed as being foolish, and of playing "Vatican roulette". They hear the admonition that 'everyone knows that rhythm doesn't work'. In the face of critical opinion, couples using natural methods believe in the rightness of their judgment and in their ability to regulate their reproductive fertility through a process of rational decision making char- acterized by self-regulation and periodic abstinence. This very ability is itself a sign of maturity. Given the thinking of Branden, the type of mature choices and judgments on the part of couples using natural methods should definitely help to strengthen and to maintain healthy self-esteem. Summary Comments: Efforts have been made throughout the discussion of the findings to establish the fact that, aside from the measurement results and differen- ces in self-esteem and marital satisfaction, there are definite character- istic differences between MGa and MGb. These differences stem from the basic appraoch each group has taken to the issue of conception regulation 65 within the context of their marriages. Each couple has made a decision for a particular method of conception regulation. The circumstances under which this decision was made are outside the parameter of this study and remain unknown. Reasons for deciding upon a particular method are con- tained in Appendix H. In general, two basic philosophical approaches can be delineated which serve to highlight characteristic differences between groups of couples and may help to explain the test differences between couples. Those couples who have chosen a contraceptive approach mention most often that the greatest benefit for them is that the method they use pre- vents pregnancy. This statement is in line with the fundamental philoso- phy of all birth control efforts. This goal can be sought after for a number of reasons and concerns: 1) the issue of world population and therefore the resulting need to limit or avoid children; 2) the danger of future pregnancies for the health of the wife; 3) financial restraints for the support of additional children. For whatever the reasons, a con- traceptive approach to conception regulation, in general, seeks to employ the most effective mechanisms for the avoidance of pregnancy. When con- sidered in contrast with a natural method approach, the contraceptive ap- proach appears quite narrow within the context of the marital relationship. Couples who have chosen a natural method approach to the issue of conception regulation, although they may have similar reasons and concerns, place a greater emphasis on the relational aspects of their marriage, i.e. that using natural methods holds the possibility of contributing to their marital relationship and personal self-confidence. This relational aspect is a factor most often spoken of in the literature on natural methods. Beyond regulating conception of new life, couples using natural methods 66 come to an awareness that the very dynamics involved in using a natural method serve to regulate their marital relationship. It is an inherent characteristic of a natural methods approach to conception regulation that it be broader in scope. Although use of such methods does aim at serving conception regulation, other benefits for the whole of the marital relationship are also sought. Earlier in the review of literature (p.12) the work of the Kippley's (1975) was cited. There it was mentioned that some of the benefits accruing from natural methods use include: the recurring opportunities to think about the meaning of mar- riage, sex and spiritual values; mutual decision making; increased respect of wives for their husbands; and learning non-genital but sexual ways of showing marital affection. When we add to these benefits the collegial aspect of learning and being supported in the use of a natural method of conception regulation, it becomes evident that couples using natural methods are often reaching outside of themselves into a social network. This reaching out involves trust and confidence in others for feedback and support. What develops from this behavior can be seen as a type of a non-formal system capable of positive influence on personal esteem and on the marital relationship. This very system dynamic holds the possibility for meeting one of the dan- gers within any marriage: that of isolation and inwardness. When any sys- tem becomes turned in upon itself, and is not stimulated or challenged by factors outside itself, it can too easily develop a distorted view of re- ality. In a social structure in which interdependencies between and among systems is growing, in which isolationism can herald the death of a sys- tem, it becomes all the more important for the maintenance and growth of the marriage system that couples be involved in an interactive and inter- dependent network of other couples for mutual support and life-giving 67 possibilities. It is the personal conviction of this researcher that the decision for using natural methods and the process and social involvements which occur as a consequence of this decision have definite positive bene— fits for the marital relationship. The findings of this present research appear quite supportive for such a conviction. CHAPTER V Conclusions,pLimitations of Study and Suggestions for Further Research Introduction: The present research has considered the question as to whether or not the use of natural methods of conception regulation does have a posi- tive effect on the personal self—esteem of couples and on their marital relationship. A comparative methodology was employed to test the hypo- theses developed around this question. The objective was to determine if there are any differences in the self-esteem levels between couples who use natural methods and those couples who do not use natural methods. A further objective was to discern to what extent, if any, it could be said that the method of conception regulation used has an effect on a person's self-esteem. The results of the data analysis indicate that there are differen- ces in self-esteem levels between couples according to the method of con- ception regulation used. Couples with high marital satisfaction who use natural methods are statistically discernable from couples who use contra- ceptive or surgical methods. This difference is more evident between couples who use natural methods and couples who have been sterilized. No causal statements can be made, however, as to whether or not use of a par- ticular method has a direct effect on self-esteem. . Conclusions based upon the results of the data analysis need to be stated with qualification. When interpreting the conclusions which 68 69 follow it is extremely important to weigh them in light of the sampling problems encountered and the selection bias which entered into the meth- odology. Additionally, the reader is advised to familiarize himself] herself with the limitations and generalizability of the study when inter— preting the conclusions reached. Conclusions: Based on the findings of this study of 45 Catholic couples, 15 of whom use natural methods of conception regulation, 11 of whom are steri- lized and 19 couples who use a variety of contraceptive methods or no method, the following conclusions have been reached: 1) Catholic couples in this study who are presently using natural methods of conception regulation demonstrate higher levels of self-esteem, as measured by the TSCS, than do couples who are using other methods and who are grouped as a whole. 2) Differences in self-esteem scores were found to be more pro- nounced for wives than for husbands, giving some support to Bardwick's thesis that the area of reproductive fertility is for women a source of identity and self-esteem. 3) Catholic couples who have been sterilized evidence, as a gIOUP. lower self-esteem and marital satisfaction. Differences between reported marital satisfaction and the FéMA score re- sults may be indicative of cognitive dissonance reduction. This may be due to unconscious guilt about behavior contrary to the teachings of the Catholic Church on sterilization. 4) Based on the comparison.made with a national sample, the con- ception regulation behavior of the couples in this study (excluding the selected groups of couples using natural methods) 5) 6) 7) 70 does not differ significantly. The results of the 1975 National Fertility Study indicate that more and more couples regardless of religious denomination are choosing sterilization (Westoff and Jones 1977). A significant percentage of couples in this study have made a decision for sterilization instead of using other effective methods of conception regulation such as the Pill and IUD. Although couples using natural methods of conception regulation experience some difficulties with abstinence, they are, never- theless, satisfied with the method used, and report that they would continue using such a method even after family size is achieved. Difficulties do not appear to be detrimental to either self-esteem or to marital satisfaction. Independently of method of conception regulation use, the major- ity of husbands and wives (n=62) demonstrate moderate to high levels of self-esteem. This was also true, but to a lesser extent, for levels of marital satisfaction (n=50). Based on the difficulty of obtaining from a population of 750 Catholic couples an adequate sample of couples who use natural methods, a final conclusion needs to be drawn. There remains a great need for education within the Catholic community to acquaint couples with the existence of the more scientifically developed natural methods for conception regulation. Not only must the existence of these methods be communicated but, more importantly, the research findings and writings relative to the marriage building potential of using natural methods needs to be communicated. Educational efforts in this area should not 71 only be directed to persons already married but to the engaged during marriage preparation programs and to high school students in their sex education classes. Generalizability: Any generalizations beyond the couples who participated in this study must be made with great caution. Caution must be advised due to three factors: 1) the research methodology of a volunteer sample; 2) the selection bias present in the subsample of couples who use natural methods; and 3) the characteristic differences evident between MIGa and MGb. The research methodology limits the conclusions to the couples who participa- ted because of the volunteer character of the subjects. However, a Cornfield-Tukey argument could be made to extend the generalization of this study's findings to Catholic couples who have identical population characteristics with these couples described in this research. Genera- lizability then might be extended to populations of Catholic couples who are middle class, highly educated, have been married between 1 and 25 years with an average family size of 2-3 children, and are living within an urban metropolitan area of the Great Lakes region. Limitations of Present Study: The present study could have been.more conclusive and powerful had there been tighter control on extraneous variables which influence self- esteem and on variables which help maintain internal validity. This issue is problematic with social science and quasi-experimental research, and has been elaborated upon by Campbell and Stanley (1963). The key vari- able Operative in the present study which could have affected the inter- nal validity of the study is what Campbell and Stanley refer to as: "biases resulted in differential selection of respondents for comparison 72 group" (Campbell and Stanley 1963, p.5). This was discussed earlier in the considerations surrounding problems of sampling procedure. The usual 'way out' of committing such an error in methodology is to assure a random sampling of subjects. Since this was not possible within the confines of this study, the results will have to be judged in the light of possible internal invalidity. Additional variables were also not taken into account or were over- looked in designing the study. No attempt was made for obtaining a thor— ough marital and family history. The research on self-esteem indicates correctly that self-esteem is learned in the early years of childhood de— velopment and is strongly influenced by the self-esteem of parents and adult care-givers (Branden 1969; Hamacheck 1978; Coopersmith 1967). Self- esteem can change beyond adolescence, but changes come much more slowly. No methodology controls were present for discovering what the self-esteem of couples was prior to using a particular method of conception regulation. The possibility exists that levels of self-esteem could have been the same. In addition, current studies in family therapy (Boszormenji-Nagy and Spark 1973; Watzlawick, Beavin and Jackson 1967) adequately show the formative influence of families on our attitudes and behavior. How persons approach the marital relationship, what they bring to it by way of attitudes and expectations strongly influences marital dynamics and decisions. Had specific questions about family influence -- feelings about oneself prior to using present method of conception regulation -- been asked, then, at least, some partial control over the historical variables may have been possible. There are two additional known variables which were unaccounted for with the study: 1) length of time in using a particular method of con- ception regulation; and 2) the instructional process by which many of the 73 couples using natural methods learned the method. The length of time in using a particular method was focused upon in the research by Ziegler et a1 (l966)in their study of sterilized couples. They found differences in test results between 1 and 4 years after the operation. There was no question within the FPQ (Form B) to consider the variable of time use. WOuld there also be some differences among couples who use other contraceptive methods other than sterilization, given varying lengths of time use? Although untested at this time, the question of length of time in using a method is also of importance for those couples using natural methods. Confidence with any skill or task should increase over time. The more confident a couple becomes in using a natu- ral method to space children or avoid a pregnancy would certainly have some effect on their self—esteem. They would feel good about themselves and their decision because they had been able to master what is seen by many to be a difficult and demanding discipline. Unlike Form B of the FPQ, Form A did contain a time use question. Since there was no similar question in Form B no comparison could be made and thus the information about time use has gone unreported thus far. Since this variable should be considered in future research, it will be sufficient to note at this time that the range of use for natural methods was from 6 months to 5 years or more with a mode of 3 to 5 years. A significant variable which separates Method Group A couples from Method Group B couples is the instructional process by which Method Group A couples learned a natural method. Two-thirds of these couples reported that they had received special instructions in natural methods of con- ception regulation. Within such classes couples are more likely to be sensitized to human sexuality and its many expressions within the marital 74 relationship. Through the input of knowledge about reproductive physi- ology and male-female response patterns, couples can come to know and be more sensitive to one another. In addition, it is assumed that the use of natural methods provides for more occasions between husbands and wives to communicate about their sexual needs and emotional responses to one another. Harrington (1974) and Kippley and Kippley (1975) note that couples who attend instructional classes in natural methods and who elect to use such methods tend to be more mature and stable in their marital relationship. It is possible to propose then, that given this assumption, couples in this study using natural methods would have scored higher on self-esteem and marital satisfaction prior to the use of natural methods. It is the historical and prior experience variables which are most plaguing to research such as the present study. The complexity of human behavior and fluctuations of response over time make measurements and conclusions about such subjective attitudes as self-esteem and marital satisfaction problematic. Suggestions for Further Research: The findings and conclusions which have resulted from this study can be extended into further research investigation. 1) Given the differences among Catholic couples who use either natural methods or contraceptive/surgical methods of conception regulation it would be worthwhile to replicate this study using couples of similar background but of different religious affil- iation. It is well known within the field of natural methods education that numerous non-Catholic couples do use natural methods for reasons other than Church teaching. A study com- paring Catholic and non-Catholic couples who use natural 2) 3) 4) 75 methods with couples of varying religious affiliations who use contraceptive methods would broaden the question of conception regulation within marriage beyond a Catholic question. The low scores on both self-esteem and marital satisfaction among Catholic couples in this study who have been sterilized Open the question as to whether further research would result in similar findings among non—Catholic couples. No causal statements were able to be made concerning the rela- tionship between natural methods of conception regulation used and self-esteem. Does the use of natural methods contribute to higher self-esteem or are couples with high self-esteem more likely to choose natural methods? In order to test for such a connection, further research would need to be longitudinal in scope. Married couples who are not presently using a natural method, but have decided to begin using such methods, would need to be tested on self-esteem and interviewed concerning marital and family history prior to learning the method. Appropriate follow up testing, interviews, monitoring of the instructional process, and investigation into changes of behavior and manner of relating to one another would need to be conducted. Obvious- ly, this type of research would help to maintain a tighter con- trol on influencing variables and would require a much more elaborate design and more refined instruments. Since mutual commitment and mature cooperation are necessary for the successful use of natural methods it would be worth- while in future research to use a self—esteem instrument which measures not only an individual's self-esteem but each spouses' 5) 6) 76 esteem attitude toward one another. The research cited within the literature review on marital sat- isfaction stressed the importance of the instrumental role of the husband for the happiness of the marriage. Because the use of natural methods requires the full cooperation of the husband, further research should focus on his affective role, as well as his instrumental role, in the marital relationship. During the process of data analysis and interpretation of the results it became more and more evident that a key influencing variable for couples in MGa is the educational and follow up processes involved in learning and being supported in the use of a natural method. It would be very beneficial in future research to study these processes as they would be operative among the populations served by various natural family planning centers . APPENDIX A 77 APPENDIX.A INITIAL LETTER Dear Parishioner: As a part of my graduate studies at Michigan State University I am undertaking a research project focusing on marriage and family life. I am sure you will agree that the Church needs a far better understanding of marriage and family life today. You can contribute to achieving this objective with a willingness to participate in this study. The focus of my research study is on the marital relationship and its importance in the planning and development of family life. If you decide to participate in this very important undertaking, I ask that you sign the enclosed consent form and, using the self-addressed stamped en- velope, return it immediately so that the necessary materials can be mailed to you. WHAT WILL A.DECISION TO PARTICIPATE IN THIS STUDY INVOLVE? A decision to participate will involve the completing of two self- administered tests, and the filling out of one questionnaire. This will be done in the comfort of your own home without the interference of any interviewer. In total, the tests and questiOnnaire should take only about an hour of your time. An important question which may have already come to your mind or may present itself if you decide to participate is that of anonymity and confidentiality. For the utmost success of this study very careful steps have been taken to ensure complete confidentiality and anonymity. Your completed tests and questionnaires will be returned to an independent party who will have no knowledge of who you are or your parish affil- iation. The materials you complete and return will contain no coded information which would enable a matching with names on the mailing list. Your names are not to appear on any test materials. Materials will be sent to you in two separate mailings. In order to keep a temporary record of returns, and to enable a second mailing of material to you, a coded return envelope will be enclosed with each mailing. These envelopes will be destroyed immediately upon mailing you the second test and questionnaire. The only material I will receive from the independent assistant will be the completed materials which bear no identification, except whether it was filled out by husband or wife. 78 Each mailing will contain specific instructions. My hope is that you will decide to participate in this study so that we can grow in our understanding of married and family life. If you decide not to participate, I ask one small favor of you. On the enclosed "Consent Form" I ask that you state your reasons for not wishing to participate. In order to maintain your anonymity, and encour- age your honesty of response, please cross out the identification number on the return envelope. Thank you for your consideration of this request. If you have any questions or need some clarification about the nature of this research study, please feel free to call me, APPENDIX B 79 APPENDIX B CONSENT FORM For the purpose of research and contributing to an increase in an understanding of married and family life, we agree to participate in the study being conducted by Fr. Joseph Tortorici, O.P. of Michigan State University. By giving our consent we agree to complete all materials sent to us. These materials will include: a self-concept scale, a marriage and family adjustment scale, and a questionnaire on family planning. It is our under- standing that complete anonymity and confidentiality will be maintained. The information we give will be used for the research purpose of writing a Masters thesis. Further, it is our understanding that we will receive no financial payment for our participation. If at any time during the course of this study we feel that we no longer wish to participate, we understand that we can withdraw. Husband Wife APPENDIX C 80 APPENDIX C PERSONAL INFORMATION (To be completed by both husband and wife) Age: Wife Husband Years of marriage: Number of children: (circle) 1 2 3 4 5 6 Years of education completed: (circle) Wife: High school 1 2 3 4 College 1 2 3 4 Graduate School 1 2 3 4 Degree(s) attained Husband: High school 1 College 1 Graduate School v—INN Degree(s) attained Family Income: (This would include combined incomes if both of you are working) CHECK APPROPRIATE SPACE _____Under $2,999 _____$3,000-$5,999 _____$6,000-$9,999 _____ $10,000-14,999 _____$15,000-$19,999 _____ $20,000-$24,999 ____ $25,000 and over APPENDIX D 81 APPENDIX D FAMILY-MARITAL ADJUSTMENT INSTRUMENT Directions: Indicate the degree of your agreement or disagreement with each of the following items as it applies to your immediate family (husband,wife and children). On the accompanying answer sheet (computer form) fill in the appropriate numbered box with your response. First impressions are satisfactory, and most people are able to complete this inventory in 10 minutes. It is quite important that you give a response to each item, even though it may sometimes be difficult to make a decision. On the answer sheet in the space for NAME please write in HUSBAND or WIFE. ' Scale: Strongly Agree Agree Neutral Disagree Strongly Disagree 1 2 3 4 5 Example: 1. "We usually can depend on each other" IF you strongly agree fill in the box labeled #1. Use_pencil. PLEASE NOTE THAT THE NUMBERS FOR EACH QUESTION ON THE ANSWER SHEET GO FROM LEFT TO RIGHT. SOCDNO‘UJ-‘th—fi HHHHHH Uwat—no 00.... 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. We can usually depend on each other. We have a number of close friends. We feel secure when we are with each other. We do many things together. Each of us wants to tell the others what to do. If we had more money most of our present problems would be gone. There are serious differences in our standards and values. We feel free to express any thoughts or feelings to each other. Our home is the center of our activities. We are an affectionate family. It is not our fault that we are having difficulties. We do not spend enough time together. Little problems oftne become big ones for us. We do not understand each other. We get along very well in the community. We often praise or compliment each other. We do not talk about sex. We take care of each other. We get along much better with persons outside the family. We are proud of our family. We do not like each other's friends. There are many conflicts in our family. We are usually calm and relaxed when we are together. We are all responsible for our family problems. we respect each other's privacy. Accomplishing what we want to do seem to be difficult for us. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 82 We tend to worry about many things. We are continually getting to know each other better. We encourage each other to develop in his or her own way. There is not enough discipline in our family. We have warm, close relationships with each other. Together we can overcome almost any difficulty. We really do trust and confide in each other. The family has always been very important to us. We get more than our share of illness. We rarely hurt each other's feelings. We are considerate of each other. We can stand up for our rights if necessary. We have very good times together. We live largely by other people's standards and values. Usually each of us goes his own separate way. We are full of life and good spirits. We resent each other's outside activities. We have respect for each other's feelings and Opinions even when we differ strongly. We sometimes wish we could be an entirely different family. We are sociable and really enjoy being with people. We are a disorganized family. We are satisfied with the way in which we now live. We are not really fond of one another. We are a strong, competent family. We just cannot tell each other our real feelings. We are not satisfied with anything short of perfection. We forgive each other easily. We usually.reach decisions by discussion and compromise. We can adjust well to new situations. Our decisions are not our own, but are forced on us by circumstances. We are a deeply religious family. APPENDIX E 83 APPENDIX E Fm“ A FAMILY PLANNING QUESTIONNAIRE This questionnaire Husband being answered by: Wife DIRECTIONS: The following questions are of a personal nature and are intended to help in the understanding of a very important aspect of married and family life. Please answer frankly and honestly. If you wish to elaborate on any of the questions feel free to use the back of the last page. If any question is no longer applicable to your situation write in NA (not applicable) and if possible indicate the reason. NOTE: The term "conception regulation" is being used in this questionnaire . The popular term is "birth control", but since "birth control" also includes the use of abortion I have chosen to use "conception regulation" to specifically refer to the control or regulation of pregnancy. What size family do you desire? (circle) 1 2 3 4 5 6 Are you and your spouse currently pregnant? Yes No (If you and your spouse are pregnant please answer the rest of the questions relative to the natural method of conception regulation used prior to pregnancy) Which natural method of conception regulation are you currently using? 1. Calendar rhythm 2. Temperature ____ 3. Sympto-Thermic ____ 4. Ovulation method (Billings' mucus observation) ___ 5. A combination of the above methods Which combination? How long have you been regularly and consistently using this method? 1. 6 months or less 2. 1 year or less 3. 2 years ____ 4. 3 to 5 years ____ 5. Longer than 5 years ____ How many years How were you instructed in the method you are using? . Special course of instructions .___ Pre—Cana or pre-marriage instructions By a doctor By a nurse By a priest By a friend Through your own reading and study \IO‘U'IbWNH o 10. 11. 12. 84 Please rate your confidence in this method of conception regulation in helping your achieve your desiredfamily size. 1.' Absolutely confident ____ 2. Confident, most of the time 3. Confident, some of the time 4. No confidence Are you satisfied with the method of natural conception regulation you are using? (circle) Yes No Sometimes Not sure Reasons for satisfaction: (check those that apply ) . Effective, i.e. prevents pregnancy No side effects' Healthy way of conception regulation Convenient and easy to use ____ Removed from the time of sexual intercourse Helps our marital and sexual relationship Other \lO‘UIJ-‘le—I Reasons for dissatisfaction: (check those that apply) 1. Ineffective I___ 2. Has uncomfortable side effects ‘___ 3. Interfers with our sexual love making ____ 4. Causes too many disagreements and arguments 5. Health ____ ‘ 6. TOO much abstinence 7. Other What are the principle things you took into consideration when making a decision about usin a natural method of conceptiop regplftipn? (check those that apply us ng a rank order procedure, .e st, n , rd, etc.) . Spacing of children ____ . Enough money to raise children well ____ . Church teaching ____ Effectiveness of the method Professional goals and plans Educational opportunities Personal health Other oouoxmwaT-a Has the use of a natural method of conception regulation in your marriage helped you feel more positive about your marital Yes No relationship with your spouse? What is the greatest benefit to you in using a natural method of conception regulation? 13. 14. 15. 16. 17. 18. 19. 20. 21. 85 What is the greatest difficulty you experience in using a natural method of conception regulation? Are you using a natural method to: (check) 1. Avoid a further pregnancy 2. Space your children 3. Achieve a pregnancy If you have children, have you ever been successful in using a natural method in actually planning the conception of Yes NO a child or children? Have not been using the method long enough to tell yet In your Opinion has the use of a natural method Yes NO served to increase marital harmony and satisfaction? Do you consider your knowledge and understanding of natural methods to be: 1. Very good 2. Adequate 3. Insufficient Would you like to have more education about human reproduction and natural methods of conception regulation? Yes No Perhaps Do you plan to continue using a natuaral method of conception regulation? (circle) Yes No Not sure Maybe Since using a natural method of conception regulation have you experienced: (check those that apply) . Extreme anxiety about a possible pregnancy . An unplanned pregnancy ____ . A great deal of confidence in regulating your fertility . Mainly an increase in marital satisfaction ____ . Mainly sexual frustration and dissatisfaction with your spouse . Other O‘UI-L‘WNO—I Has the Church's teaching on contraception had anything to do with your choosing a natural method of conception regulation? 1. Not at all 2. Somewhat 3. Very much 22. 23. 24. 25. 26. 27. 28. 86 DO you ever worry about a surprise pregnancy when using a natural method of conception regulation? 1 . Never __ 2. Sometimes 3. Often ____ 4. Very often If for any reason you do not wish to have sexual intercourse with your spouse how is your refusal usually received? 1. With understanding and love: often sometimes never 2. With some criticism and Often sometimes .never negative comments: 3. With silent resentment: often sometimes never How do you feel about your own refusal to have sexual intercourse? 1. Frustrated: often sometimes never 2. At peace: often sometimes never 3. Misunderstood: often sometimes never 4. Guilty: often sometimes never 5. Accepted & loved: often sometimes never DO you ever use barrier methods of contraception during the fertile time? 1. Never .___ 2. Seldom ____ 3. Once in a while 4. Often In deciding to use a contraceptive method during the fertile time how was the decison made? 1. By both of us 2. By myself 3. By my spouse (WIFE) At which time during your mentrual cycle do you feel most amorous and desire sexual intercourse? 1. During the fertile days .___ 2. Days before your menstrual period ____ 3. Days immediately preceding ovulation ‘___ 4. Days immediately following ovulation 5. Not sure (HUSBAND) When does your wife seem more desirable to you for sexual intercourse? 1. During the fertile days .___ . Days before her menstrual period .___ . Days immediately preceding ovulation .___ . Days immediately following ovulation ____ . Not sure U'IbUN 29. 30. 31. 32. 33. 34. 35. 36. 37. 87 Do you and your spouse both agree on the use of a natural method of conception regulation? Yes No Do you ever argue about the issue of conception regulation? Often Once in a while Seldom Never Does the topic of conception regulation and your present practice ever interfer with your marital relationship, i.e. does it cause bad feelings? (circle) Often Once in a while Seldom Never Does the topic of conception regulation and your present practice ever enhance your marital relationship, ie. does it casue good feelings? (circle) Often Once in a while Seldom Never Once you achieve your desired family size will you continue Yes No Maybe to use a natural method of conception regulation? If no, which method of contraception do you thing you might consider? In your opinion has the use of a natural method of conception Yes No regulation improved your marital communication? If you have used contraceptive methods in the past, why did you discontinue their use? (check those that apply) . Inconvenient ___ 6 Bothersome ' Pregnancy ____ No confidence “___ Insufficient knowledge Sexually frustrating 7. Abstinence was too difficult 8. Caused too much tension in marital relationship U1b~uak3h- Please check which contraceptive method you used prior to using a natural method of conception regulation. (check those that apply) Pill 1. 2. IUD 5. Withdrawal 3. Diaphragm 6. Foams and Jellies 4. Condom 7. None 8. Combination of methods (please specify which combination) ********************* THANK YOU FOR YOUR PARTICIPATION 1 APPENDIX F 88 APPENDIX F FORM B FAMILY PLANNING QUESTIONNAIRE This questionnaire Husband being answered by: Wife DIRECTIONS: The following questions are of a personal nature and are 1. 5. intended to help in the understanding of a very important aspect Of married and family life. Please answer frankly and honestly. If you wish to elaborate on any of the questions feel free to use the back of the last page. _If any question is no longer applicable to your situation write in NA (not applicable) and if possible indicate the reason. NOTE: The term "conception regulation" is being used in this questionnaire. The popular term is "birth control", but since "birth control" also includes the use of abortion I have chosen to use "conception regulation" to specifically refer to the control or regulation of pregnancy. What size family to you desire? (circle) 1 2 3 4 5 6 Are you currently pregnant? Yes No (If you and your spouse are pregnant please answer the rest of the questions relative to your conception regulation practices prior to pregnancy) Are you presently using any particular method of conception Yes NO regulation? What are the principle things you took into consideration when making a decision about which method of conception regulation you would use in planning your family? (check those that apply by using a rank order procedure,i.e. lst, 2nd, 3rd, etc. ) 1. Spacing of children 2. Enough money to raise children well 3. Church teaching 4. Effectiveness of the method 5. Professional goals and plans 6. Educational Opportunities 7. Personal health 8. Other Which method of conception regulation are you using most consistently? 1. Pill 5. Withdrawal 2. IUD 6. Foams and Jellies 3. Diaphragm 7. Sterilization (Vasectomy, Tubal ligation) 4. Condom 8. Abstinence 9. None 10. 11. 12. 13. 89 Have you always used the method(s) checked in question Yes No #5? If you answered, No, what other methods have you used? (check) 1. Pill 5. Withdrawal 2. IUD 6. Foams & Jellies 3. Diaphram 7. Natural family planning 4. Condom a. Temperature b. Ovulation method c. calendar rhythm 8. None What reasons led you to discontinue the method of conception regulation you checked in question #7? 1. Lack of faith in the effectiveness of the method ___ 2. Pregnancy(ies) 3. Bothersome ___ 4. Frustrated my desire for intercourse 5. Frustrated my spouse's desire for intercourse ___ 6. Interruptive 7. Health reasons 8. Other Are you satisfied with your present method of conception Yes No regulation? Reasons for satisfaction: (check those that apply to you personally) 1. Effective, ie. prevents pregnancy 2. No side effects .___ 3. Convenient and easy to use ___ 4. Removed from the time of intercourse ___ 5. Helps our marital and sexual relationship 6. Other Reasons for dissatisfaction: (check those that apply) 1. Ineffective ___ 2. Has uncomfortable side effects ___ 3. Interfers with our sexual love making ___ 4. Causes too many disagreements and arguments ___ 5. Health ____ 6. Other Do you and your spouse bOth agree on the method of conception Yes No regulation being used? Do you ever argue about the issue of conception regulation? (circle) Often Once in a while Seldom Never 14. 15. 16. 17. 18. 19. 20; 21. 22. 23. 90 Does the topic of conception regulation and your present practice ever interfer with your marital relationship, i.e. does it cause bad feelings? (circle) Often Once in a while Seldom Never Does the topic of conception regulation and your present practice ever enhance your marital relationship, ie. does it cause good feelings? (circle) Often Once in a while Seldom Never If you have been sterilized, would you do it over again? Yes If Yes - Why? If No - Why not? Do you and your spouse ever worry about a suprise pregnancy? 1. Never 3. Often 2. Sometimes 4. Very often Please rate your confidence in your method of conception regulation in helping you achieve your desire family size. 1. Absolutely confident 2. Confident, most of the time 3. Confident, some of the time 4. No confidence In your opinion has the use of your present method of conception Yes regulation improved your marital communication? Has the use of a conception regulation method in your marriage Yes helped you feel more positive about your marital relationship with your spouse? What is the greatest benefit to you in using your present method of conception regulation? What is the greatest difficulty you experience in using your present method of conception regulation? (WIFE) At which time during your menstrual cycle do you feel most amorous and desire sexual intercourse? . During the fertile days ____ . Days before your menstrual period I___ Days immediately preceding ovulation Days immediately following ovulation Not sure Ln-l-‘Ler-a No No No 24. 25. 26. 27. 28. 29. 91 (HUSBAND) When does your wife seem more desirable to you for sexual intercourse? 1. During the fertile days . Days before her menstrual period . Days immediately preceding ovulation . Days immediately following ovulation . Not sure Mwa If for any reason you do not wish to have sexual intercourse with your spouse, how is your refusal usually received? (circle) 1. With understanding & love: Often sometimes never 2. With some criticism and Often sometimes never negative comments: 3. With silent resentment: often sometimes never How do you feel about your refusal to have sexual intercourse? 1. Frustrated: often sometimes never 2. At peace: often sometimes never 3. Misunderstood: often sometimes never 4. Guilty: often sometimes never 5. Acdepted & loved: often sometimes never Have you ever tried using any of the following natural methods Yes No of conception regulation? (check those you have tried) 1. Calendar rhythm 2. Temperature ____ 3. Ovulation method (Billings' mucus observation) 4. Sympto-Thermic method If you have, please check the reasons for discontinuing. . Inconvenient ____ . Bothersome . Pregnancy . No confidence . Insufficient knowledge ____ 6. Sexually frustrating 7. Abstinence was too difficult ____ 8. Caused too much tension in marital relationship LnJ-‘UJNH If you have never tried a natural method of conception regulation please check the reason(s) why. . Had no reliable knowledge of an effective method . Heard it was unsafe ____ . There was no one to teach us . Did not want to become pregnant No confidence Too inconvient Other \JO‘LflL‘WNH 30. 31. 92 Once you achieve your desired family size will you continue to use your present method of conception regulation? Yes No Maybe If No, which method of conception regulation might you then consider? ******************* THANK YOU FOR YOUR PARTICIPATION ! APPENDIX C 93 APPENDIX G RESPONSES TO OPEN ENDED QUESTIONS (FORM A)* Question 8: Reasons for satisfaction with method 1. Easy and reliable. 2. Wife knows what is going on with her body. 3. Helps to appreciate each other more._ Question 9: Reasons for dissatisfaction with method 1. Tea many things besides ovulation affect temperature. 2. My wife is very irregular and therefore we sometimes abstain for long periods when we're not quite sure of what's going on. 3. It's extremely difficult to be consistent in checking all the things - this is why we must abstain a lot, due to missed checking. Question 10: What are the principle things you took into consideration when making a decision about using a natural method of conception regulation? 1. Concern for wife and her health - effects of continual use of pill - her age and possibility of defective children. 2. Age - 42 years old. 3. Personal moral values (trying to be based on Scripture). 4. Personal conviction that natural birth planning is the Lord's way for His people. 5. Confidence that this method is God's will for us in our circumstances. 6. Felt other means were out of God's order. 94 APPENDIX G (Cont.) Question 20: Since using a natural method of conception regulation have you experienced: 1. Frustration - in that we are unable to have relations when the desire and need is the strongest. When.we need each other the most it is always that time of the month. 2. Frustration - guilt feelings of having to say "no" to husband's strong natural feelings. 3. A.certain degree of frustration, but pp£_with my spouse. 4. A great deal of confidence knowing when you are and are not fertile. *All responses are individual. The reader is referred to APPENDIX E for a fuller context for the above questions. The responses contained here in APPENDIX C were written in under the heading of 'other'. APPENDIX H 95 .. I .. .. H I I SEE n N a I m I I nuau>om m n m N m H m nume e w m m m H N auMHm m e o a m a w Summon NH m N m m w aH ouHeB OH H m HN m NH HH vacuum «H I I «H mm cu m umuHm on How: aOHumosom mHmoul . mmucofinuoommm wag—onus HmHoamnHm $5225 9395 we Hmaomuom HoaOHmmumoum anyone oHHsu MJOHOHOHm mmHnooo HH< cocoa: :OHumstom GOHunooooo mo OUHOSU Mom maommum m Nanmmm< APPENDIX I 96 APPENDIX I Raw Total Positive Scores - TSCS (Matched Pairs) MGa ‘M Husband Wife Husband Wife 340 340 294 221 380 393 365 341 334 340 340 387 326 383 303 - 363 357 402 378 391 354 365 346 332 360 367 350 346 332 357 390 409 384 320 320 350 355 369 376 326 383 392 367 371 327 355 264 326 381 384 334 327 432 393 298 278 371 351 355 358 336 326 321 309 355 371 405 371 373 294 387 372 318 334 366 405 367 363 366 337 300 291 316 348 346 348 344 389 370 350 APPENDIX J Husband 146 154 145 112 134 169 156 136 122 145 158 122 155 162 139 _Wifg 123 157 129 155 153 161 158 130 100 160 157 92 155 155 122 97 APPENDIX J Raw F-MA Scores (Matched Pairs) Husband 88 133 145 106 155 142 137 167 78 133 162 77 124 108 127 132 74 125 153 82 50 146 128 135 127 128 113 125 113 79 MGb Wife {3% 1 142 159 141 145 149 180 93 167 172 116 100 140 150 131 94 158 157 124 76 118 142 145 154 137 138 130 150 70 BIBLIOGRAPHY BIBLIOGRAPHY Aller, Florence A., "Role of the Self-Concept in Student Marital Adjustment," Familprife Coordinator, 1962, Vol. 11, pp. 43-45. Allport, Gordon Willard, Personality: A Psychological Interpretation. New York: H.Holt and Company, 1937. Ball, John and Nancy, Joy in Human Sexuality. Collegeville: The Liturgical Press, 1975. Bardwick, Judith, "Psychodynamics of Contraception.with Particular Reference to Rhythm," In William.Uricchio and Mary Kay Williams (eds.), Proceedings of a Research Conference on Natural Family Plannipg, Washington, DC: The Human Life Foundation, 1973, pp. 195-212. (a) Bardwick, Judith M., Paycholggy of WOman - A Study of Bio-Cultural Conflicts. New York: Harper and Row, 1971. (b) Benedek, T. and Rubenstein, B.B., "The Sexual Cycle in Women: the Relation Between Ovarian Function and Psychosomatic Processes," Psychosomatic Medical Mbnographs, 1942, Vol. 3, pp. 1-307. Berger, Charles Riedel, "A Factor Analytic Study of Self-Esteem," Unpublished Masters' Thesis, Michigan State University, 1966. 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