Fertility Awareness-Based Methods to Prevent Pregnancy – KFF

 

Report on Fertility Awareness-Based Methods (FABMs) and Sustainable Development Goals

Introduction: Contraceptive Choice and Global Health Objectives

Fertility Awareness-Based Methods (FABMs) are a category of contraceptive techniques that involve tracking ovulation to prevent pregnancy. These methods are integral to achieving Sustainable Development Goal 3 (Good Health and Well-being) and SDG 5 (Gender Equality) by expanding the range of available family planning options. Users may select FABMs for various reasons, including religious beliefs, a preference for hormone-free contraception, or as part of a combined contraceptive strategy. While FABMs offer an alternative to pharmaceutical or device-based methods, their efficacy rates are generally lower than other reversible contraceptives like oral pills or IUDs. Recent policy discussions and social media trends have increased the prominence of FABMs, necessitating a comprehensive analysis of their role in public health, particularly in relation to universal access to reproductive healthcare as outlined in SDG Target 3.7.

Analysis of Fertility Awareness-Based Methods

Methodological Framework

FABMs operate by identifying the approximately six-day fertile window within a menstrual cycle. Successful implementation for pregnancy prevention requires abstinence or the use of barrier methods during this period. The methods contribute to SDG 5 by empowering individuals with knowledge about their own reproductive cycles. A distinction is often made between FABMs and “natural family planning” (NFP), with NFP specifically excluding barrier methods and being promoted by certain religious institutions.

Classification of FABMs

• Calendar-Based Methods: These include the Rhythm Method and Standard Days Method, which use past cycle lengths to predict future fertility. Their reliance on cycle regularity makes them less suitable for individuals with variable cycles, posing a challenge to consistent application and impacting health outcomes (SDG 3).
• Symptom-Based Methods: These methods require monitoring physiological indicators of ovulation. Achieving proficiency often necessitates education and training, highlighting the importance of SDG 4 (Quality Education) in reproductive health.
  • Basal Body Temperature (BBT) monitoring
  • Cervical mucus observation
  • Urine hormone level measurement
• Lactational Amenorrhea Method (LAM): This postpartum method relies on exclusive and frequent breastfeeding to delay ovulation. Its effectiveness is contingent on strict adherence, linking directly to maternal and child health objectives within SDG 3.

Role in Reproductive Medicine

FABMs are also foundational to practices such as “Restorative Reproductive Medicine” and “Natural Procreative Technology” (NaPro), which aim to address infertility without assisted reproductive technologies. These approaches align with the broader goal of providing comprehensive reproductive health services (SDG 3).

Efficacy and Public Health Implications

Usage and Effectiveness Rates

In the United States, approximately 13% of women aged 18-49 have used FABMs. The effectiveness of these methods is highly dependent on correct and consistent use, which underscores the need for robust health education systems (SDG 4). Failure rates with typical use can be significant, ranging from 2 to 34 pregnancies per 100 women annually. This variability has direct implications for achieving SDG Target 3.7, which aims to ensure universal access to family planning and reduce unintended pregnancies. In contrast, methods like IUDs and implants have failure rates of less than one per 100 women with typical use.

Limitations and Barriers to Access

Challenges to Effective Implementation

The potential for human error makes FABMs less effective than many alternatives. Key challenges include:

1. Significant User Commitment: A learning period of several cycles is often required, during which users may be at risk of unintended pregnancy.
2. Daily Monitoring Requirements: Consistent and accurate observation and interpretation of fertility signs are necessary.
3. Partner Cooperation: Successful use requires commitment from both partners, reinforcing the importance of shared responsibility in reproductive health as a component of gender equality (SDG 5).

Systemic and Provider-Level Barriers

FABMs are not universally suitable, particularly for individuals with irregular menstrual cycles or certain health conditions. This can create inequalities in contraceptive access (SDG 10). Furthermore, healthcare providers in Title X clinics have identified barriers to offering FABMs, including a lack of training, time constraints for counseling, and a preference for more reliable methods. These provider-level challenges impede the delivery of quality, comprehensive family planning services as envisioned by SDG 3.

Technology, Access, and Equity

Technological Integration

Modern FABM practice is increasingly supported by technology, from simple calendars to sophisticated mobile applications and devices that track BBT or use algorithms to predict fertility. The Natural Cycles app, cleared by the FDA as a contraceptive device, exemplifies this trend. While technology can improve ease of use, it also introduces a digital divide, potentially exacerbating inequalities (SDG 10) for those without access to smartphones or the internet.

Data Privacy and Institutional Responsibility

The use of health apps raises significant data privacy concerns, particularly in contexts where reproductive rights are contested. The need for robust regulation and transparent privacy policies from tech companies aligns with SDG 16 (Peace, Justice and Strong Institutions), which calls for accountable and transparent institutions to protect individual rights.

Economic Factors: Cost and Insurance Coverage

Financial Accessibility and SDG 10

The cost of FABMs varies, from free apps to expensive subscriptions and instructional courses that can exceed $200. This financial barrier directly impacts SDG 10 (Reduced Inequalities) by limiting access for low-income individuals. While federal guidelines recommend offering a full range of contraceptive methods, actual coverage is inconsistent.

Insurance Coverage Disparities

Although the FDA-cleared Natural Cycles app is covered by most private insurance plans under the ACA, coverage often requires a prescription and is limited for Medicaid recipients. The lack of consistent coverage for FABM supplies and instruction creates a significant gap in achieving equitable access to family planning, a cornerstone of SDG 3 and SDG 5.

The Role of Information and Misinformation

Navigating the Social Media Landscape

Social media is a pervasive source of information—and misinformation—about contraception. Narratives promoting FABMs while making false claims about the harms of hormonal methods are common. This environment undermines progress toward SDG 4 (Quality Education) by hindering individuals’ ability to make fully informed health decisions. Analysis of platforms like Pinterest and TikTok shows a trend of presenting FABMs with more benefits than barriers, while the opposite is true for hormonal methods, creating a biased information ecosystem that can negatively impact public health outcomes.

1. Which SDGs are addressed or connected to the issues highlighted in the article?

SDG 3: Good Health and Well-being

• The article’s core subject is contraception and family planning, which are fundamental components of sexual and reproductive health. It discusses various Fertility Awareness-Based Methods (FABMs), their efficacy, use, and limitations, directly relating to ensuring healthy lives and promoting well-being for all at all ages. The text explores different options for preventing pregnancy, which is a key aspect of individual health management.

SDG 5: Gender Equality

• Access to comprehensive family planning information and a range of contraceptive methods is crucial for gender equality. It empowers women to make informed decisions about their reproductive health, which in turn affects their educational, economic, and social opportunities. The article discusses women’s choices regarding hormonal vs. non-hormonal contraception, the influence of social media on these choices, and the importance of access to services, all of which are central to achieving gender equality and empowering all women and girls.

SDG 10: Reduced Inequalities

• The article highlights inequalities in access to reproductive healthcare based on economic status. The discussion on the “Coverage and Cost” of FABMs, including the price of apps, thermometers, and instructional classes, points to financial barriers. Furthermore, it contrasts coverage under private insurance plans (mandated by the ACA) with limited coverage under Medicaid, indicating that women with lower incomes may face greater challenges in accessing certain FDA-approved contraceptive methods.

2. What specific targets under those SDGs can be identified based on the article’s content?

SDG 3: Good Health and Well-being

• Target 3.7: “By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes.”
  • The article directly addresses this target by examining FABMs as a method of family planning. It discusses the provision of these methods through programs like Title X and family planning clinics (“60% of all family planning clinics and 81% of Planned Parenthood clinics offered FABM instructions or supplies”). It also highlights challenges in access to information, such as the spread of misinformation on social media and a lack of clinician training.

SDG 5: Gender Equality

• Target 5.6: “Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences.”
  • This target is reflected in the article’s focus on providing women with a full range of contraceptive options to exercise their reproductive rights. The text notes that “offering women the full range of FDA-approved contraceptive methods, including FABMs, is a critical element of quality family planning care.” The discussion of why women choose FABMs (e.g., religious objections, preference for hormone-free methods) underscores the importance of respecting individual choice in reproductive health matters.

SDG 10: Reduced Inequalities

• Target 10.3: “Ensure equal opportunity and reduce inequalities of outcome, including by eliminating discriminatory laws, policies and practices and promoting appropriate legislation, policies and action in this regard.”
  • The article connects to this target through its analysis of healthcare policies and their impact on access. It mentions the ACA’s contraceptive coverage policy as a measure to ensure equal opportunity. However, it also points out inequalities of outcome by stating that for the FDA-cleared Natural Cycles app, “As an over-the-counter product, coverage is not necessarily required under Medicaid. In a 2021 KFF state survey of Medicaid family planning services, few states reported covering Natural Cycles in their programs.” This highlights a policy-driven gap in access for women reliant on Medicaid compared to those with private insurance.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

Indicators for Target 3.7 and 5.6 (Universal Access to Family Planning)

1. Proportion of women using contraceptive methods: The article provides a specific data point: “Data from the 2024 KFF Women’s Health Survey show that 13% of women ages 18 to 49 used FABMs as contraception at some point in the last year.” This can be used to track the uptake of different family planning methods.
2. Availability of family planning services: The article provides a clear metric for service availability: “From 2022-2023, 60% of all family planning clinics and 81% of Planned Parenthood clinics offered FABM instructions or supplies.” This measures the extent to which services are integrated into the healthcare system.
3. Access to accurate information: The article implies an indicator related to the prevalence of misinformation. It states that “nearly four in ten (39%) women of reproductive age saying they have seen or heard something on social media about birth control in the past 12 months,” much of which involves “false claims.” This suggests a need to measure and counter health misinformation.

Indicators for Target 10.3 (Reduced Inequalities)

1. Cost as a barrier to access: The article details the costs of various methods, which can serve as an indicator of economic barriers. For example, “Natural Cycles has a $150 annual subscription” and instructional classes for the Creighton Model “can easily exceed $200.” These figures can be compared against income levels to assess affordability.
2. Disparities in insurance coverage: The article points to a direct indicator of inequality in healthcare policy. The fact that “few states reported covering Natural Cycles in their [Medicaid] programs,” while it is covered by “most major health insurance plans” under the ACA, serves as a clear measure of unequal access to the same health product based on insurance type and, by extension, income level.

4. Create a table with three columns titled ‘SDGs, Targets and Indicators” to present the findings from analyzing the article.

SDGs	Targets	Indicators
SDG 3: Good Health and Well-being	3.7: Ensure universal access to sexual and reproductive health-care services, including for family planning, information and education.	Percentage of family planning clinics offering FABM instruction or supplies (60% of all clinics, 81% of Planned Parenthood clinics). Percentage of women of reproductive age who have seen or heard information about birth control on social media (39%).
SDG 5: Gender Equality	5.6: Ensure universal access to sexual and reproductive health and reproductive rights.	Percentage of women (ages 18-49) who used FABMs in the last year (13%). Availability of a full range of FDA-approved contraceptive methods as a standard of quality care.
SDG 10: Reduced Inequalities	10.3: Ensure equal opportunity and reduce inequalities of outcome, including by eliminating discriminatory policies.	Out-of-pocket costs for contraceptive methods (e.g., $150 annual subscription for Natural Cycles, over $200 for Creighton Model classes). Disparity in insurance coverage for contraceptive methods between private insurance (ACA mandate) and Medicaid programs (“few states reported covering Natural Cycles in their [Medicaid] programs”).

Source: kff.org