Are Women Ditching Birth Control for Fertility Awareness? (Episode 597)

Full Transcript: Episode 597

Lisa Hendrickson-Jack:

In today’s episode, I’m tackling a really interesting and important question. So the topic of today’s episode is are women ditching birth control for fertility awareness? And so in this brand new episode of our FAMM Research Series, we are diving into a study that was conducted in the UK. And the title of the study is self-reported contraceptive method use at conception among patients presenting for abortion in England, a cross-sectional analysis comparing 2018 and 2023.

So this study is really interesting. We’re going to dive into the different points of it. I’m really excited to dive into it. I have a really interesting perspective on it, and I think so do the researchers, but unsurprisingly they don’t necessarily match my opinion to their opinion. So let’s go ahead and dive into the data.

So, as I’ve been covering on the podcast pretty consistently, pretty extensively, there does seem to be this theme coming out in a lot of different research studies highlighting this huge problem that’s going on in the reproductive space. And the huge problem according to the researchers is that more and more women are turning away from hormonal contraceptive methods in favor of fertility awareness-based methods. And of course they are often presenting this as due to social media. So I’ll give you a quote from the study that they have kind of in their overview just to set the stage. So quote, “Largely anecdotal and some qualitative data suggests that younger women are turning towards more natural methods of contraception, including withdrawal and the use of mobile phone apps, so-called period tracker apps, to facilitate use of the calendar method and track fertility, hereafter referred to as fertility awareness-based methods.” End quote.

So basically, I mean, already they kind of have my antenna up because already they are doing the thing that I always talk about them doing. So if you were to basically include — if you were studying condoms and you were to include people who don’t even wear them when they have sex, then you would get this incredibly skewed view of condoms and think that they don’t even work. But half of the population that you’re studying, for example, in my hypothetical example, aren’t even wearing them. So, does that give you an accurate view of the effectiveness of the actual condom? Well, I would argue no. And so, right off the bat, they’re telling you that anybody who says they have a period app is using a quote fertility awareness-based method, and they’re including that in their analysis. And that is intellectually dishonest and just completely ridiculous if you actually know what fertility awareness-based methods are.

So, first and foremost, no surprise to anybody, I’m going to start with the premise that a true fertility awareness-based method is separate from someone who just tracks their period and has no idea about what’s going on. You can hardly call that a method, but this is literally how they’re starting the study. So, we’ll continue. Let’s talk a little bit about the study and how they designed it and what it was all about.

So basically what they did is they have — I’ll read here just this first sentence here. British Pregnancy Advisory Service, BPAS, is an independent healthcare charity that provides medical and surgical abortion through a network of clinics and telemedicine hubs in England and Wales. So this is their organization that they’re looking at, and what they did essentially is have the nurses and midwives who are working in this facility conduct interviews with women who are seeking termination of their pregnancy, and they are asking them what types of birth control they were using and recording them. So this study is a cross-sectional comparative analysis. And what they did is they compared a period of time in 2018 for women seeking termination, medical termination, from January to June 2018. And then they had another group of women from January to June of 2023. And what they said in the study was that they wanted to kind of eliminate some of the issues around the COVID situation. So they wanted to have a population kind of before that and a population after that so they could compare these two groups and see what the trends were. They didn’t want their results to be confounded by all the challenges related to that period of time that we all kind of know about.

All right. So that kind of sets the stage and then their findings are pretty interesting. So what they found — and they grouped the different methods that were reported by these women who were seeking out these services. So they grouped them into fertility awareness methods, hormonal contraceptives, but you know if someone was using a long-acting reversible contraceptive, if someone was using like an IUD or like an implant, then that was in a separate category. So all hormonal methods weren’t necessarily together. So primarily the hormonal contraceptives might be like the pill, the patch, that kind of thing. And then they had users that had no method and then they had users that reported other methods. And in other methods, they included things like condoms and they included vasectomy sterilization. They didn’t clarify if withdrawal was included in other methods. They just said that withdrawal was not included in the fertility awareness-based methods. And as I previously mentioned, anybody who said they have used an app is included in this.

So what they found was that there was a significant, statistically significant, increase in users who reported that they used basically period apps or as they term fertility awareness-based methods. But we don’t really have a clear breakdown into like what percentage of these women just tracked their periods versus which percentage of these women used a symptothermal method that they were trained from an instructor. Right? So we don’t have that information. Anybody who used a period tracker would have been put in this category and therefore they’re calling that FABMs.

So there was an increase in 2018. So in 2018, 0.4% — so less than 1% of users said that they were using period tracker apps or other FABMs. And in 2023, 2.5% reported that they used period tracker apps or FABMs. So this represents a 525% increase, which obviously is significant, like 525% increase. But as I mentioned, the actual total volume of women who were using these methods, it went from less than 1% — 0.4% — to 2.5%. So that means 97.5% of the women who are reporting to get this procedure who had an unintended pregnancy were not using charting apps or fertility awareness-based methods.

Okay. So I’m going to continue. So the study also found that the use of hormonal contraceptives decreased. And as I mentioned they exclude some of the longer acting like the IUD placement or implant. But the use of hormonal contraceptives decreased. So in 2018, about 19% of their patients reported that they were using hormonal contraceptives, and in 2023 about 11% were using. So there was a 40% decrease in the number of women reporting for medical termination who used contraceptives. So they did see a pretty significant decline in women who were using hormonal contraceptives. And then the long-acting contraceptives, there was an 80% decline. Now, if someone has an IUD placed or if somebody has an implant, obviously those methods statistically have a lot higher of an efficacy rate and a far lower user error margin, because if you get an IUD placed or an implant put in, like you can’t really mess it up. You’re solely based on the effectiveness of the actual method.

So it’s not surprising. So in 2018, 3% of the women seeking termination reported that they used these long-acting methods. And then in 2023 less than 1%, so 0.6%. So there was an 80% decrease in the users who said that’s the method that they were using.

Now, what’s interesting is that the category of no method used at the time of conception increased significantly. So there was about 56% of users in 2018 who reported using no contraception at all. And then in 2023, 70% of users — women who had an unintended pregnancy and were asking for this procedure — 70% used no contraception. So there was approximately a 25% increase in the number of women who were seeking termination because they were not using a contraceptive method at all.

So before I get into just talking a little bit about the data and what they found, I just want to share with you from their perspective how they presented this. So they’re really heavily focusing on FABMs. This is what I find so interesting. I just finished saying that in 2023, 70% of the women who were seeking termination were using no method at all. Yet, they found the most significant piece of information to discuss — the 2.5% of women in 2023 who reported using period tracker apps — so that they can throw FABMs under the bus because they didn’t even assess the different types of methods and look at how many of those women were actually using a specific method and potentially using it correctly.

So I think there’s that. And so they’re focusing on, oh my goodness, there was this drop in the percentage of women who were using contraceptives, who reported that they were using hormonal contraceptives. There was a drop in the women who reported using these long-acting methods. And of course, they’re looking at the increase in the number of women who were using no method. And they’re kind of saying, well, there’s this trend on social media for people to be using more natural methods. And so they’re kind of like pretending like that’s the problem. I guess because I think it’s so interesting if you have results like this and you see that 70% of the women seeking termination in 2023 based on your study had reported the use of no method at all, then how are we hyperfocused on the fact that 2.5% used a period tracker app?

I would argue that a woman who uses a period tracker app is not using birth control if she’s having unprotected sex. That would be my argument. So my argument would be that could just go right in with the non-users, and if somebody actually isn’t using a specific charting method, they shouldn’t be included. So their focus of this paper is that this is the real problem. The real problem is that these women are hearing about these natural, ineffective — according to them — methods of birth control and they’re turning away from more effective hormonal contraceptive methods. And so this is the real problem. The real problem is that all these women should be on hormonal contraceptives and if all of them were on contraceptives, we would have fewer unintended pregnancies.

Now, there may be — that may be a valid point. I mean, that’s certainly a perspective that we could look at. But I think there’s a couple things that we want to talk about. So I definitely wanted to kind of share how they presented it. So I just want to read a quote from their conclusion and then we’ll get into it a little bit more. So quote, “There appears to have been a significant increase in the proportion of individuals attending this abortion clinic who used FABM” — again, fertility awareness-based methods, that’s what they’re calling women who are using period tracker apps as a form of contraception — “and are using no method of contraception. This may be a result of preference or it may be related to difficulties with access to more effective methods of contraception in the preconception and post-abortion periods. Further research needs to be undertaken to investigate this hypothesis.”

So yeah, like I said, I think there’s a couple things we should be looking at. I already mentioned I feel like the bigger issue to me at least seems that there’s such a high percentage of women reporting that they’re using no method of birth control. And obviously what happens if you use no method of birth control? Research tells us over and over again that 80% of healthy individuals who have sex for a year are going to get pregnant if they don’t use any type of contraception. And so that seems to be a big challenge.

And there was one quote in the study that I thought was really interesting. And the reason I thought it was interesting is because if you really are being honest, you can’t get away from the actual data that is related to FABMs. So while they’re saying that FABMs have a high failure rate, they acknowledge in their kind of introductory summary section of the paper — they said, however, greater use of less effective methods could lead to a higher rate of unintended pregnancy and demand for abortion. And they say the typical use failure rate for FABM ranges from 2 to 23 in 100 in the first year of use compared with 7 in 100 for combined hormonal methods. And it’s less than 1 in 100 for IUDs.

And so again, one of the significant criticisms I’ve had on studies that are looking at FABMs is that you really have to look at what they’re including. So when we’re looking at 23% failure rates, they’re often including these period tracker apps that are so-called programmed with algorithms that are telling women when their fertile window is. And so those calendar rhythm-style options don’t fit under the definition of modern FABMs, especially because it’s not evidence-based. There’s not really evidence on a period tracker app. There’s evidence on certain apps, few and far between, but even those apps have been shown to — it’s an algorithm. So there are issues with these algorithms.

So what’s interesting though is that they say the typical use failure rate ranges from 2 to 23. And so that means that there are fertility awareness-based methods that are effective even with typical use compared to 7 in 100 for combined hormonal methods. So even that — a lot of people don’t realize that hormonal contraceptives have a failure rate and that typical use is not 99%. So with combined oral contraceptives, that means that they’re not 100% effective, or they’re not 99% effective with typical use. They’re — according to their data — 93% effective, which is not 100. And so therefore, if someone’s using hormonal contraceptives, combined contraceptives — typical use, not like perfectly, but typical use — there will be some unintended pregnancies.

So I think that part is interesting because they actually do acknowledge, when you look at the data, they have to acknowledge that there’s this range. And the question for me is, well, if you’re looking at that range, why aren’t you questioning why some methods are 2% with typical use compared to the 7% with typical use for hormonal contraceptives? And some methods are the 23%. Why are we not kind of looking at that and identifying that as an issue?

So ultimately they’re looking at this situation and instead of focusing on the 70% of women who are experiencing these unintended pregnancies and ending up in their clinics, they’re tackling the 2.5% of women who are using the charting apps and saying that’s the real problem here.

So there’s that. And ironically, if you have 70% of women who are using no method, they could benefit from using fertility awareness-based methods even with their loose definition, because according to their loose definition, there’s a 23% failure rate with these charting apps. And so, wouldn’t that be better than the 80% failure rate of not using any method?

So I think that there’s just different ways of looking at this, but the first point that I’m making here is that they’re not addressing the larger problem. So obviously I’ve highlighted extensively that app users I would say are not necessarily fertility awareness users. So this study I would say is based on a false premise, because right off the bat they’re basically including women who are not using a true fertility awareness-based method and they’re calling it fertility awareness-based method because that’s how it appears in the literature. And I feel like that is based on a bias and their opinion that fertility awareness-based methods — all of them — are totally ineffective, all of them are the same as calendar rhythm, and therefore no one should use them. And I think that is unfortunate because they’re really pushing this idea as opposed to looking at the data and really investigating it.

So they’re misdiagnosing — as far as I’m concerned — the real issue here. The other thing I want to point out is that by definition they are looking at a population of women whose method failed them. They’re looking at a population of women who are likely either not using a method at all — 70% in 2023 — or potentially using their methods inconsistently or incorrectly. So they’re also looking at a specific population who has all had unintended pregnancies. And so you’re not really looking at a general broad population of women overall. You’re looking specifically at the individuals who had an unintended pregnancy or otherwise a method failure. And interestingly, when you look at the data, most failures are user-related, not necessarily method-related.

And so, again, it’s interesting. I mean, even when we look at failure rates like typical use versus perfect use for the condom, for example. I even had an interesting conversation — I was interviewed on a podcast and the woman who interviewed me was in her 20s, she was in her late 20s, and we were having this conversation and I shared with her one of the observations that I’ve made as someone now who’s in their 40s. So in my generation, the sex education — so some of you will remember this or relate to this — the sex education in my generation was like, if you have sex, you’ll get AIDS and die. And so therefore, you should use condoms all the time. And they really stressed STIs and obviously they really stressed HIV and AIDS. And so they told us to wear condoms. And they said condoms are 98% effective in preventing pregnancy. You should wear them. And I remember learning how to use condoms. Like I actually learned how to use them. I’m not saying that the education system was so great. I think there was different opportunities to learn how to use them. I remember in university, I remember going to this thing where this woman put the condom over her arm and she rubbed oil on it and it snapped. So I don’t know what was going on. Maybe it was just my university. There were different programs on the television. I remember — if any Canadians are out there — Degrassi High. I remember seeing this. It was like Snake. She put like, was that her name? Spike, that was her name. She put like a condom over a banana or something. And then we had Sue Johansen, the Sunday Night Sex Show. So many Canadians might be remembering some of that stuff. But I just remember that even though the education system in the school wasn’t so great and we didn’t necessarily learn about all of how to use condoms, I learned how to use condoms because there was a whole discussion around that, and even the programs that I was watching as a teenager had some information that was sort of educational. So I just feel like for whatever reason in my generation, a lot of us learned how to use condoms properly because condoms were actually pushed. They told us to use them because of this whole if you have sex you’ll get AIDS and die thing. But I do feel like for the younger generation that just totally stopped. It became hormonal contraceptives only and therefore that’s the only method that they’re promoting.

And so the education around just how to use contraception at all, how to use non-hormonal methods — there’s no education on diaphragms, like there’s just nothing. And so it’s like hormonal contraceptive only. And they just kind of assume that’s — I would argue that they’re not even educating about hormonal contraceptives. I think the average person couldn’t list anything or more than a few things that could interfere with the effectiveness of their contraception. Right? So there’s just no education.

So I think — and I could be wrong, so correct me if I’m wrong — but I think again that this study is looking at data and skewing it in a certain way. They’re saying that there was a decrease in reported hormonal contraceptive use. What if that means that there are more women who are using their contraceptives correctly and therefore fewer of them are having an unintended pregnancy? What if the lower percentage is because the method was working? And you know, like, what if the method was working and that’s why you’re seeing fewer women report that type of use? And maybe the fact that there are so many more women who reported using no method — what if it’s just that the women who were using the methods correctly were actually successfully avoiding pregnancy versus the fact that if you use no protection, you’re far more likely to have an unintended pregnancy if that’s not your desire.

So I do think it’s so interesting because again, this data set is really specific. This data set is specifically people who had an unintended pregnancy only. And so therefore, they either used no method or they used their methods incorrectly. Right? So they’re giving you this rationale. They’re saying the reason is because you have more women turning to fertility awareness-based methods and they’re not effective. More women reported using charting apps. Therefore it’s the social media that’s making women not want to use contraceptives. That’s why we’re having more pregnancies — while not acknowledging that 70% of the women who were in your study literally said that they used no protection at all. And maybe that’s the issue. Maybe the issue is an educational issue. Maybe we need to figure out why they’re not using a method. What’s going on? Maybe that is part of what would have to change. We would have to have a conversation and have some sort of education about it. Or maybe we just have to have a conversation about how to use certain methods correctly. But the issue is presented as — oh well, the whole problem is that not enough women are on birth control, so we got to get them all on birth control. And that’s really the only solution. And FABMs — we can’t have them using those. Everyone needs to be on birth control.

So yeah. So I think it’s so interesting. I mean, if you have this study and you’re seeing the overall picture, we’re going to focus on the 2.5% instead of the 70%.

So I think that kind of brings me to the end of what I wanted to talk about today with regards to this study. I just wanted to share some thoughts on it because I’m seeing this trend of research really demonizing fertility awareness-based methods, criticizing it and blaming this whole — oh, more women are coming off birth control — and that is seen as this huge problem. Instead of them asking why. So instead of them kind of saying, well, why are women dissatisfied with contraception?

The one great thing that we have going for us is that hormonal contraceptives — the first pill came out in 1960. And so we have a significant amount of data on hormonal contraceptives, which is great. We have 65 years worth of data. And so there’s no shortage of research on birth control. And I think that’s part of their problem. We have a lot of evidence of the side effect profile. We have a lot of evidence in terms of how many women are dissatisfied. We have studies that show that 50% of women who go on a combined oral contraceptive pill come off within the first year because they’re dissatisfied with the side effects. And so instead of blaming social media and blaming fertility awareness-based methods, why don’t you look at your own data and ask why is it that 50% of women are coming off of my product within the first year? Maybe if you just looked at that and then actually read it and listened to what these women were saying and tried to come up with a solution for their problems — instead of just: their solution is just take it, or just try another one, just keep trying. Try this one. Okay, we have this brand. We have this other brand. Okay, try the IUD. Okay, do the implant. Okay, do the shot. Just try something. We’ve got all of these basically versions of the same thing. And hopefully one of them gives you fewer side effects. I mean, this is literally their solution.

And while this is all happening, women are now talking about it more and a lot of women are looking for other alternatives. And instead of looking at why that is, it’s always this like demonization.

So if you found this episode to be interesting and you’re wanting to take a peek at the study, you can head over to fertilityfriday.com/597. If you can think of somebody who would benefit from hearing this, I would encourage you to share this episode. That is one of the ways that we get the word out about the podcast. And it’s really been a grassroots movement from our listeners sharing the podcast, sharing the resources of course that I’ve cultivated as well. I talk extensively about the birth control pill in The Fifth Vital Sign as well as my newer book co-authored with Lily Nichols, Real Food for Fertility. So definitely take a peek at some of those resources. Ironically, in both books the pill chapter was chapter 7. And there is some new research and information in Real Food for Fertility that wasn’t necessarily covered in The Fifth Vital Sign.

So with that said, I hope you have a wonderful week, wonderful weekend whenever you’re tuning into the show. And I suppose one thing that I’ll say, which is not the typical way that I end the episode, is that when you’re looking at research, definitely look at it critically and always think to yourself: where are the researchers coming from? And is this the only way that this data could be interpreted? Is there another way that we could interpret this data?

So with that, I will leave you today and yeah, enjoy your weekend, enjoy your week, and I will see you soon.