March 1, 2018
To Whom It May Concern,
Thank you for providing the Association of Fertility Awareness Professionals (AFAP) with the opportunity to provide feedback about how the CDC presents information regarding Fertility Awareness-Based Methods (FABMs) of contraception.
AFAP is a professional membership organization of Fertility Awareness educators and allies. We have adopted and adhere to high standards of educator certification and promote access to high quality Fertility Awareness education for individuals and couples of all identities and orientations. The content of our instruction is free from religious values, except for those of our clients, if disclosed.
As such, we are extremely grateful for the chance to comment on CDC’s materials pertaining to FABMs, especially in light of the public efforts of FACTS about Fertility and other organizations petitioning the CDC for change in this area last spring. As we stated in our blog post May 16, 2017, AFAP does favor more clarity around effectiveness statistics and we are committed to increasing the public’s access to evidence-based, up-to-date, and unbiased information about FABMs. However, we chose not to sign the petition in part because we seek a more collaborative and collegial path toward change. So, thank you for the invitation to take a step along that way!
We appreciate that interpreting and sharing data about FABMs is complicated by a number of factors: there are many different methods and practices that fall into the FABM category; practices are not always standardized; and the FABM clinical effectiveness literature is relatively small and has a number of methodological limitations. We are very excited about the systematic review of FABM effectiveness underway by AFAP members Rachel Urrutia, M.D., and Chelsea Polis, Ph.D., and their team (which was presented at the North American Forum on Family Planning on October 14, 2017), and about Dr. Polis’s work as a reviewer on the contraceptive effectiveness chapter and an author on the FABM-specific chapter in the next edition of Contraceptive Technology. Retrospective surveys (such as the National Survey of Family Growth, which we understand informs CDC recommendations), although providing data that can generate contraceptive effectiveness estimates generalizable to users in the United States, are currently unable to contribute to clarity around the effectiveness of individual FABMs. Because the number of FABM users is quite low in the US, the pregnancy rate is calculated for all women who self-report use of any FABM, although the actual effectiveness of individual FABMs with established rules for identifying the timing of the fertile window may vary. Furthermore, the vast majority of women classified as FABM users in the United States report using “calendar rhythm”, and it is unclear whether these women are following the established rules of the rhythm method, or using an informal (and perhaps erroneous) understanding of the timing of their fertile window. Thus, while calculating a single effectiveness rate for FABMs in NSFG data is analytically justifiable, it may contribute to a lack of public understanding of the various kinds of FABMs that exist, and that each may have unique effectiveness profiles and other characteristics.
Despite these complexities, we believe that more complete and specific information about FABMs should be provided, to the extent that current research allows. We believe this would help ensure that people are able to exercise informed consent when choosing a contraceptive method. The internet and developments in technology mean that people are increasingly likely to have heard or read something about Fertility Awareness or menstrual cycle tracking. There are over 1,000 apps designed to track the menstrual cycle. A subset of these apps are marketed for use as a contraceptive, and at least one (Natural Cycles) has approval by the EU as a contraceptive. Healthcare providers may be increasingly approached with questions about FABM use. Among the Certified Fertility Awareness Educators in our organization, anecdotes abound regarding clients who are met with dismissiveness, derision, and even misinformation when they question their healthcare providers about these contraceptive options. Ideally, from our perspective, such a question would open a deeper discussion about the different kinds of FABMs, including, perhaps, information to promote greater body literacy and a discussion of the user involvement required, the availability of fertility awareness training, etc.
The CDC is in a uniquely powerful position to educate the public and the healthcare community about FABMs to support informed choice. There are many avenues in which the CDC could take the lead. We would welcome discussion on any FABM-related issue. To start, we offer these ideas about the information most readily available on the CDC website:
“Contraception: How Effective Are Birth Control Methods?” Currently, when a health practitioner or lay person lands on the CDC website page with this title (a likely result of an internet search of “contraceptive effectiveness”), they see a brief intro and multiple tabs, with the first tab, “Downloadable Resources” open, and showing a pdf of a chart and a poster of efficacy for a variety of birth control methods. There are a few ways in which we feel the information about FABMs in particular could be presented more clearly. For example:
1. Regarding the tab, “Downloadable Resources”:
a. PDFs of a handout and poster cite a 24% typical use failure rate for FABMs in general. The handout has a side-note that refers to Standard Days and TwoDay Methods, but there is no mention of other FABMs, including those which have moderate quality effectiveness data showing relatively lower failure rates. Each category of FABM (e.g., mucus-based, calendar-based, symptothermal, etc.) uses the observation of particular biomarkers to identify the fertile window. This allows for a number of options that may appeal to specific subpopulations, thus expanding contraceptive choice.
b. The side note refers to Standard Days and TwoDay as the “newest” methods – but the meaning of “newest” is unclear. We are aware of more recently developed methods, but more importantly, the term may inadvertently imply “most advanced”. It also states that ease of use may make these methods more effective than other FABMs; though this may not be evidence-based.
c. We would like to see this information on the pdfs rewritten to eliminate these ambiguities and expanded to include information on other FABMs including the Symptothermal Method, Billings Ovulation Method, Natural Cycles, etc., perhaps highlighting those backed by at least moderate quality effectiveness research. We note that the WHO has recently expanded their website to include such data.
2. Regarding the tab, “Reversible methods of birth control”:
a. Under this tab the CDC has the opportunity to expand on the information presented in the “Downloadable Resources.” This could be the place where additional information about a variety of FABMs could be explained. This could be similar to the way that different barrier methods, hormonal methods, and IUDs have been distinguished in the text above.
b. Although it is often used interchangeably with Fertility Awareness Based Methods, the term “Natural Family Planning” is associated with the religious practice of Fertility Awareness endorsed and promoted by the Catholic church, which requires chaste abstinence during the fertile time. Our understanding is that amongst most fertility awareness educators, the term “Fertility Awareness Based Methods (FABMs)” is understood as a broader umbrella term. Therefore, we would encourage use of the term “FABM” (rather than NFP) if and when referring to practices wherein other methods (such as barrier methods or withdrawal) may be used during the fertile window, or when vaginal intercourse is avoided during the fertile window in a secular context. Use of the term NFP is more appropriate when describing use of an FABM within a religious context, which is intended to be practiced with use of abstinence during the fertile window.
c. The link titled “monthly fertility pattern” takes people to a womenshealth.gov article about how to conceive. We are concerned that this reinforces the idea that FABMs are for achieving pregnancy, and are not a viable option for contraception.
“MMWR Appendix D: Contraceptive Effectiveness” The chart here breaks down the perfect use effectiveness rates for four different FABMs (Standard Days Method, TwoDay method, Ovulation Method, Symptothermal Method). We wonder if a table like this (which allows for more detailed information than the tiered visual overview of contraceptive options discussed above) could be more prominently featured on the CDC website. The WHO includes this and more information on their readily available page, “Family-Planning/Contraception,” updated July 2017.
The specific suggestions above touch only on the most readily available information on the CDC website. There are many opportunities for discussion regarding the way information about FABMs is communicated. We hope the CDC will provide leadership around presenting detailed and accurate information on FABMs, so that visitors to the CDC website will be better informed, and so that healthcare providers will be more empowered to respond to patient requests for information on FABMs.
We appreciate that FABM users represent a small portion of the overall population, which can inhibit calculation of robust effectiveness statistics in nationally representative survey data, and we appreciate that prospective clinical studies of FABMs are relatively few, and that many have methodological limitations. However, individuals interested in using FABMs deserve access to clear and accurate presentation of the FABM effectiveness data that does exist. New analyses have documented a small but significant increase in use of FABMs for contraception in the United States, and we have observed a rise in technology to support fertility tracking for contraception and other goals. We feel it is thus important to address the issue of FABM effectiveness in a way that highlights (both for practitioners and the general public) the similarities and differences among the various FABMs, and how one can use these methods correctly and consistently. We are grateful for you taking the time to read this letter. If the CDC would benefit from our assistance as you navigate through this process, we would be more than happy to consider assisting in any way, such as drafting materials or providing comments. As we are an all-volunteer organization, any request would need to be evaluated to ensure our organization has the capacity to fulfill it, but we welcome the opportunity to consider such requests. We look forward to your response.
Sincerely,
The Association of Fertility Awareness Professionals
Letter prepared with the assistance of the AFAP Research Committee, including members:
- Tamara Rubin, Certified Fertility Awareness Educator
- Dr. Rachel Peragallo Urrutia, Assistant Professor, Department of Obstetrics and Gynecology, University of North
Carolina - Dr. Chelsea Polis, Senior Research Scientist, Guttmacher Institute**
- Amy Sedgwick, Certified Fertility Awareness Educator, Certified Holistic Reproductive Health Practitioner
- Justina Thompson, Certified Fertility Awareness Educator, Certified Reproductive Health Educator
** Affiliation included only for identification purposes. Participation in drafting this letter was not conducted under the auspices of the Guttmacher Institute, and the views expressed herein are those of the authors and do not necessarily reflect the views of the Guttmacher Institute