I wrote the letter below to BMJ Sexual and Reproductive Health in response to the article by Amy Hough et al "Social media and advertising natural contraception to young women: the case for clarity and transparency with reference to the example of Natural Cycles" (paywall). The BMJ allows publishing of paywall content on author websites so my letter is below. To see it on the BMJ SRH website click here (paywall).
A Cochrane Review is an understandable choice but not an appropriate one. It would be more helpful to quote NHS Choices, the Family Planning Association or Faculty Guidance, which all have a more nuanced approach to the evidence, and say that fertility awareness is up to 99% effective.
Typical use rates are lower but many women achieve high effectiveness thanks to either their own research or appropriate support.
Natural Cycles is the new app that is revolutionising fertility awareness thanks to huge amounts of funding for marketing and research and a clean design that removes all judgement from the user (in a similar way to CycleBeads) and simply pronounces a day “red” or “green”.
The accessibility, if not the advertising, of Natural Cycles is welcome. Women need options. But it is not ideal.
Advertising is one issue. As Hough et al describe, because Natural Cycles is not a prescribed product, and because they have substantial financial resources, they are able to bypass health professionals and advertise direct to potential clients. They run targeted Facebook and Instagram adverts and get support from trusted social media influencers, favourable press articles and others.
Still, it is worth remembering that prescribed medication is also not free of commercial influence. As Ben Goldacre describes in Bad Pharma, not being able to advertise direct to consumers simply means Big Pharma concentrates on selling direct to trusted health professionals, researchers and influencers through educational events, smooth sales reps, research grants, lobbying and other methods.
Another issue is the lack of transparency about the Natural Cycles algorithm. There has been decades of research about fertility awareness. It is a shame that they are not adding to this in a more meaningful way – or even acknowledging it, simply saying that they have “invented” an algorithm, as if it has come out of thin air and not decades of research about different algorithms.
It is also worrying that their algorithm seems to have a “one-size-fits-all” approach. Fertility is not an on/off switch. There are days on which pregnancy is very likely, days on which it is likely and days on which it is very unlikely or impossible.
Some women use fertility awareness in a very cautious “life or death” way – not having unprotected sex till after ovulation has been and gone. Others are more willing to push the boundaries – depending on our cycles and on how we feel about unplanned pregnancy – and our age. A woman of 48 might choose to be less cautious than she was aged 38, or even 44.
We also use different fertility indicators. Some of us use temperature and ovulation sticks (in the style of Natural Cycles). Many women find temperature and fluid more convenient, or simply fluid and/or calendar calculations.
A better fertility app would have a transparent algorithm that allows women to choose the approach that suits them. It would also open up the data (in anonymised form) to researchers. This is not only an important contraceptive option, it is important knowledge. We should have an NHS app for this - not a private one.