Women’s Health Reports

Volume 1.1, 2020

DOI: 10.1089/whr.2020.0065
Accepted June 12, 2020

ORIGINAL ARTICLE Open Access

A Mixed-Methods Assessment of Health Care Providers’

Knowledge, Attitudes, and Practices Around Fertility
Awareness-Based Methods in Title X Clinics
in the United States
Shelby Webb,* An-Lin Cheng, Rebecca Simmons, Rachel Peragallo Urrutia, Victoria Jennings, and Jacki Witt

Abstract
Objective: To understand how Title X providers currently engage with fertility awareness-based methods
(FABMs) for pregnancy prevention in Title X clinics across the United States.
Materials and Methods: We developed a survey to assess knowledge of fertility for purposes of pregnancy pre-
vention, attitudes toward FABMs use for pregnancy prevention, and practices when patients request FABMs for
pregnancy prevention.
Results: In total, 329 participants who met all inclusion criteria completed the survey. Respondents were gen-
erally highly knowledgeable on fertility, felt neutrally toward FABMs or thought they were a nonviable option for
most women, and were likely to respond to patient requests for FABMs for pregnancy prevention by providing
information. Qualitative responses included several barriers to provision of FABMs for pregnancy prevention and
few successes to provision.
Conclusions: Fertility knowledge and discussion of specific methods increased with the number of methods
included in the clinic’s written materials or with the number of different FABMs someone at that clinic had
been trained on. Significant clinician or administrative barriers may exist to offering FABMs to patients. Incorpo-
rating up-to-date information on a range of FABMs—rather than treating them as one method—into contracep-
tive counseling represents an opportunity to increase the contraceptive offering for clients who want them,
leading to increased patient satisfaction and successful family planning outcomes.
Keywords: attitudes; awareness; contraception; fertility; provider; Title X

Introduction or using an alternative method of contraception during

Fertility awareness-based methods (FABMs) of family days of potential fecundity.
planning rely on women interpreting their individual There are many different FABMs, each relying on
physiological signs, such as the timing of the menstrual different method rules and one or more physiological
cycle, changes in cervical fluid, basal body temperature, signs.1 For example, the Standard Days method relies
and/or increases in urinary hormones to predict cur- only on menstrual cycle timing, and women consider
rent fecundity. The underlying contraceptive princi- themselves fertile between days 8 and 19, whereas
ple of FABMs is that people can reduce their chance symptothermal methods utilize signs such as cervical
of pregnancy by abstaining from vaginal intercourse fluid and basal body temperature in combination to

School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, Missouri, USA.

*Address correspondence to: Shelby Webb, MPH, School of Nursing and Health Studies, University of Missouri-Kansas City, 2464 Charlotte Street, Kansas City, MO 64108,
USA, E-mail: [email protected]

ª Shelby Webb et al. 2020; Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of the Creative Commons License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.

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identify fertile days. A recent systematic review found It was also sent directly to e-mail addresses on file for
moderate quality typical use pregnancy estimates for providers at Title X clinics.
12 specific FABMs ranging from 2% to 33% per Responses were included in this analysis if respon-
100 woman/years.1 dents affirmed that their primary clinic setting pro-
FABMs are the preferred method of use for a vided family planning services and received federal
small but growing number of contraceptive users of Title X family planning funds and that they held a
FABMs in the United States.2 The Office of Population clinical role in that setting (nurse, provider, etc.).
Affairs reported an increase in the number of female Responses from manager/administrators or billing/
family planning users whose primary method of con- finance staff were excluded from this analysis, which
traception is FABMs from 8784 in 2007 to 15,287 in was focused on understanding FABM knowledge, atti-
2017.3,4 People who use these methods may desire to tudes, and practices among providers of contraception
avoid hormones, adhere to religious teachings, involve and/or contraceptive counseling.
the male partner in reproductive decision making,
and/or feel more in tune to the functioning of their re- Instruments
productive system. Besides contraceptive uses, FABMs The survey instrument consisted of a 53-item survey
may also be used by women or couples to achieve created by the authors and tested by three FABM
a pregnancy or monitor health conditions, such as subject matter experts. Both the terms ‘‘FABMs’’ and
polycystic ovary syndrome and infertility.5 In turn, ‘‘NFP’’ (natural family planning) were defined in the
they must accept that these methods may be less effec- survey to ensure respondents understood that ‘‘FABMs’’
tive than some other methods and are especially sus- included all fertility tracking methods. Survey items in-
ceptible to imperfect use. People who use FABMs cluded multiple choice, true/false, yes/no options, Likert-
deserve transparent information about their effective- type, and open text questions. The survey questionnaire
ness, benefits, and challenges. is provided in Appendix A1.
Recently, the Office of Population Affairs, which ad-
ministers the Title X grant program, identified FABMs Knowledge. We assessed knowledge of fertility for
as a key topic for the Title X network, with require- purposes of pregnancy prevention with four true/false
ments for Title X providers to offer counseling on ‘‘knowledge’’ questions. These questions included iden-
these methods as part of offering a broad range of con- tification of the normal menstrual cycle length, charac-
traceptive methods. Despite increasing demand and teristics of cervical mucus around the time of ovulation,
federal attention, little is known about current provider normal basal body temperature increase after ovula-
knowledge, attitudes, and practices related to FABM tion, and length of the luteal phase.
counseling and provision,6,7 and nothing is known
about these aspects specific to Title X providers. The Attitudes. To assess provider attitudes toward FABM
purpose of this study was to understand how Title X use for pregnancy prevention, we asked the partici-
providers currently engage with FABMs for pregnancy pants to rate the viability of FABMs as a method of
prevention in Title X clinics across the United States. contraception on a Likert scale, with 1 being ‘‘a nonvi-
able option for most women,’’ 3 being ‘‘neutral,’’ and 5
Materials and Methods being ‘‘a viable option for most women.’’
To assess provider knowledge, attitudes, and practices
related to FABMs for pregnancy prevention, we devel- Practices. To assess provider behaviors, we asked par-
oped a survey for Title X-funded clinic staff across the ticipants to describe how they responded to patients
United States. requesting an FABM for pregnancy prevention. In
addition, we asked two open-text questions query-
Participants ing providers about existing barriers to providing
We posted a link to the survey on the Title X National FABMs, as well as their experiences of success in pro-
Clinical Training Center for Family Planning website viding these methods for pregnancy prevention.
and additional survey links in newsletters from the
Title X Family Planning National Training Center, Data collection
the Office of Population Affairs, and the National The survey was hosted by REDCap8 and contained a
Family Planning and Reproductive Health Association. consent script that explained the purpose of the study
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and ensured participation was anonymous and volun- Table 1. Participant and Clinic Demographics
tary. The survey was open for 11 weeks. This study was Characteristic N (%)
approved as exempt with a waiver of signed informed
Gender
consent by the University of Missouri-Kansas City Female 319 (97.0)
Institutional Review Board. Male 4 (1.2)
Nonbinary/prefer to self-describe 4 (1.2)
Primary role
Data analysis Clinical provider (NP, CNM, PA, MD, and DO) 148 (45.0)
For quantitative responses, we conducted descriptive Registered nurse 140 (42.6)
Licensed vocational/practice nurse 17 (5.2)
analyses for comparative outcomes. In addition, we con- Health educator/counselor/health care 16 (4.9)
ducted multivariable logistic regression analyses to as- associate/medical assistant
sess the associations between the number of FABMs Other 1 (0.3)
Principal setting
respondents clinics’ have training on or offer materials Health department 239 (72.6)
for and respondents’ knowledge, attitudes, and practices Hospital-based setting 15 (4.6)
toward FABMs. All quantitative analyses were con- Planned parenthood 12 (3.6)
Free-standing family planning organization 28 (8.5)
ducted using SAS version 9.4 (SAS Institute, Cary, NC).9 Community health center/federally qualified 43 (13.1)
For open text, short-answer responses on questions health center
Tribal health center 8 (2.4)
about provider successes, and barriers to FABM provi- Substance abuse treatment center 1 (0.3)
sion, we conducted emergent thematic coding to iden- Faith-based organization/setting 1 (0.3)
Correctional facility-based setting 2 (0.6)
tify existing themes and subthemes associated with Federal government setting 1 (0.3)
each question. In addition, we conducted textual analy- Private foundation or nonprofit setting 6 (1.8)
Other 2 (0.6)
ses on extension questions (e.g., ‘‘other, please specify’’)
Location
and quantitatively grouped these responses in new or Urban 85 (25.8)
existing answer categories. Suburban 50 (15.2)
Rural 182 (55.3)
Frontier 8 (2.4)
Results HHS region
An invitation to complete the survey was sent to 1. CT, ME, MA, NH, RI, VT 5 (1.5)
2. NJ, NY, Puerto Rico, Virgin Islands 15 (4.6)
8002 e-mail addresses of family planning providers 3. DE, District of Columbia, MD, PA, VA, WV 17 (5.2)
and was also placed on national websites as already 4. AL, FL, GA, KY, MS, NC, SC, TN 113 (34.3)
detailed. A total of 458 family planning providers com- 5. IL, IN, MI, MN, OH, WI 25 (7.6)
6. AR, LA, NM, OK, TX 59 (17.9)
pleted the anonymous online survey. This represents a 7. IA, KS, MO, NE 43 (13.1)
5.7% response rate of e-mailed invitations; however, 8. CO, MT, ND, SD, UT, WY 21 (6.4)
9. AZ, CA, HI, NV, American Samoa, Northern Mariana 19 (5.8)
with the inclusion of those who may have come across Islands, Micronesia, Guam, Marshall Islands, Palau
the survey on national websites, which is not possible 10. AK, ID, OR, WA 8 (2.4)
to calculate, the response rate is likely much lower. Characteristic Mean (SD)
The current sample includes 329 participants (71.8%)
Average participant age 48.65 (11.7)
who met all inclusion criteria. Average years since completing most advanced clinical 15.6 (10.9)
Of those completing the survey, 97.0% of respon- training
Average years working at clinics/sites that provide 14.1 (11.3)
dents identified as female and almost half (45.0%) family planning services
identified as clinical providers (NP, CNM, PA, MD,
Characteristic Median (IQR)
and DO), whereas another 48.0% identified as nurses.
Among respondents who reported nursing licensure, Median number of times per month counseled a 1 (10)
person/couple on FABMs/NFP for pregnancy
the largest subspecialty were registered nurses (42.6%). prevention
Providers reported a variety of practice settings, includ-
FABMs, fertility awareness-based methods; IQR, interquartile range;
ing health departments (72.6%), community/federally NFP, natural family planning; SD, standard deviation.
qualified health centers (13.1%), and free-standing fam-
ily planning organizations (8.5%) (Table 1). dents could correctly identify both luteal phase length
(91.2%) and characteristics of ovulatory cervical fluid
Knowledge (94.2%). Participants were less likely to know the typical
A majority of participants answered all of the fertility length of the menstrual cycle (80.2%), or about the shift
questions correctly (52.0%). More than 90.0% of respon- of basal body temperature after ovulation (74.5%).
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Table 2. Regression Analyses

Sum of FABMs included in written information Sum of FABMs those at facility have been
Predictor N provided to patients Beta or OR (CI) formally trained on Beta or OR (CI)

Linear regression
Belief of FABM viability 321 0.012 0.085
Knowledge score 329 0.192* 0.195*
Logistic regression
Which of the following best describes your response when a patient asks you for information about FABMs for pregnancy prevention?
Do not recommend FABMs 329 0.531 (0.232–1.213) 0.848 (0.455–1.58)
Calendar method 329 1.22 (1.04–1.44)* 1.05 (0.879–1.26)
Cervical mucus Method 329 1.54 (1.28–1.84)*** 1.48 (1.19–1.85)***
Basal body Temperature method 329 1.41 (1.19–1.67)*** 1.25 (1.03–1.50)*
Written information 329 1000 (0–1000) 1.47 (1.16–1.85)**
FABM mobile apps 329 1.55 (1.30–1.85)*** 1.45 (1.18–1.77)***
Referral to location which specializes 329 0.898 (0.718–1.122) 0.878 (0.664–1.16)
in FABM instruction
Referral to someone else in same office 329 0.270 (0.073–0.991)* 1.152 (0.822–1.62)
Other 329 0.142 (0.046–0.438)*** 1.015 (0.776–1.33)

*p < 0.05, **p < 0.01, **p < 0.001.

CI, confidence interval; OR, odds ratio.

Our multivariable regression model identified asso- dents gave an answer of ‘‘3’’ (43.8%) or ‘‘neutral,’’
ciations between the number of correct answers a par- with the second most popular answer being ‘‘1’’
ticipant reported and the reported number of different (24.6%) or ‘‘a nonviable option for most women’’
FABMs included in written information provided to (Fig. 1).
patients (b = 0.192, p < 0.05) and by the number of This response was not significantly impacted by
FABMs that they reported formal training on the number of FABMs included in the written in-
(b = 0.195, p < 0.05) (Table 2). formation provided to patients (b = 0.012, p = 0.778)
or by the number of FABMs that those at the
Attitudes participant’s facility have been formally trained on
When asked about whether they thought FABMs (b = 0.085, p = 0.087), although this number ap-
were a viable option for contraception, most respon- proaches significance.

FIG. 1. Attitudes toward FABMs. FABM, fertility awareness-based methods.

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Clinical practices Table 3. Clinical Practices

When asked to identify how they responded to patient Characteristic N (%)
requests for FABMs for pregnancy prevention, pro-
Which of the following best describes your response when a patient asks
viders generally responded by providing some infor- you for information about FABMs for pregnancy prevention? (n = 329)
mation, either verbally (32.5%–48.0%) or through I tell her they do not work and recommend something 13 (4.0)
written materials (47.1%) (Table 3). Providers were sig- else
I describe the use of the calendar method 158 (48.0)
nificantly more likely to discuss a calendar method I describe the use of the cervical mucus method 125 (38.0)
(odds ratio [OR] = 1.22, confidence interval [CI] I describe the use of the basal body temperature 107 (32.5)
method
1.04–1.44), a cervical mucus method (OR = 1.54, CI I provide her with written information on NFP/fertility 155 (47.1)
1.28–1.84), or a basal body temperature method awareness
I provide her with information about modern FABM 98 (29.8)
(OR = 1.41, CI 1.19–1.67) with patients with each addi- mobile apps
tional FABM added to the written materials available in I refer her to a location that specializes in FABM 60 (18.2)
instruction
the clinic. Providers were also significantly more likely I refer her to someone else in our office 15 (4.6)
to discuss a cervical mucus method (OR = 1.48, CI Other 40 (12.2)
1.19–1.85) or a basal body temperature method (OR = What NFP/fertility awareness methods are included in the written
information you provide patients? (n = 155)
1.25, CI 1.03–1.50) with each additional FABM that the Symptothermal 32 (20.6)
clinic had formal training on. Symptohormonal 12 (7.7)
Seventy-eight (23.7%) participants reported some- Billings Ovulation Method 37 (23.9)
Two-Day Method 25 (16.1)
one at their facility had formal training in FABMs, Standard Days 77 (49.7)
the majority being clinical providers (82.0%). Almost Natural Cycles 52 (33.5)
Lactational Amenorrhea Method 24 (15.5)
half of those respondents reported training on the Other 11 (7.1)
Standard Days method (47.4%). Respondents also Unknown 28 (18.1)
reported receiving formal training on a symptothermal Does anyone at your facility have formal training in FABMs? (n = 329)
Yes 78 (23.7)
method (19.2%), symptohormonal methods (6.4%), What best describes the primary role of those at your facility who have
Billings Ovulation method (24.4%), Two Day method formal training in FABMs? (n = 78)
(17.9%), Natural Cycles Mobile Application (25.6%), Manager/administrator 2 (2.6)
Clinical provider (NP, CNM, PA, MD, DO) 64 (82.1)
or the Lactational Amenorrhea method (25.6%) Registered nurse 28 (35.9)
(Table 3). Licensed vocational/practical nurse 5 (6.4)
Health educator/counselor/health care 13 (16.7)
associate/medical assistant
Community outreach staff 3 (3.8)
Qualitative responses Which FABMs have those at your facility been formally trained on?
(n = 78)
Barriers to providing FABMs as a contraceptive Symptothermal 15 (19.2)
option. The most commonly reported barrier (n = 77) Symptohormonal 5 (6.4)
Billings Ovulation Method 19 (24.4)
was provider perceptions that these methods were inap- Two-Day Method 14 (17.9)
propriate for their clients. Other barriers to FABMs for Standard Days 37 (47.4)
Natural Cycles 20 (25.6)
pregnancy prevention included perceptions that clients Lactational Amenorrhea Method 20 (25.6)
did not desire to use FABMs, that clients could not af- Other 5 (6.4)
ford the supplies required to use an FABM, and that Unknown 23 (29.5)

FABMs themselves are less effective methods of contra-

ception compared with other methods (Table 4). ods, or a lack of administrative support to develop
Many providers identified that they and their clinical educational materials or train staff on FABMs.
staff did not have the training to counsel on these
methods. They also noted the lack of available educa- Successes in providing FABMs as a contraceptive
tional materials to give to women interested in learning option. The majority of providers did not report
about FABMs. Many spoke about the time-intensive any successes in incorporating FABMs into their
nature of counseling on these methods and the struggle contraceptive counseling for pregnancy prevention.
to fit this type of discussion into a 15-minute visit win- Those who had successes associated them with certain
dow. Others noted funding and administrative limita- demographic groups of women who used them. Suc-
tions to inclusion of these methods in counseling cesses mentioned with incorporating FABMs in con-
such as a lack of funder reimbursement for these meth- traceptive counseling included successful use to avoid
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Table 4. Qualitative Findings Table 4. (Continued)

Examples of reported provider barriers to providing FABMs (n = 226) Examples of reported provider barriers to providing FABMs (n = 226)

Provider perceptions that these methods are inappropriate for their ‘‘Our clinic sees many clients under the age of 19. When reviewing this
clients (n = 77) as a preventive service, they are not interested in taking their
‘‘[We] have poorly educated patients who don’t know basic anatomy temperature, checking mucus, etc. Many report that it is easier to
or body functions. They have hard enough time making it to their take a pill.’’ Female registered nurse, age 46–50 years, Illinois
appointment due to lack of resources and poor schedules.’’ Female ‘‘Patients come to us for a method of birth control, not about how to
provider, age 41–45 years, Missouri prevent pregnancy using FABMs.’’ Female registered nurse, age 56–
‘‘Many patients do not seem to have the self-control or motivation to 60 years, Nevada
be strict within the guidelines of abstinent/condom times.’’ Female
provider, age 61–65 years, Indiana Examples of reported provider successes with providing FABMs
‘‘We also have many women with irregular menses and partners for pregnancy prevention (n 5 200)
that do not agree that women get to determine when sexual
contact occurs. In other words, the male partner determines No successes (n = 72)
when the couple has sex, not the female, therefore planned sexual ‘‘We have had very little success. In fact, we have had unintended and
contact is not possible.’’ Female provider, age 36–40 years, North unwanted pregnancies as a result. Stressing this as a truly effective
Carolina and viable option for women is, in my personal opinion, taking a
‘‘Most of our patients who are seeking contraception want a method huge step backward and I am disturbed to see the renewed focus
which is more reliable. We have a lot of teenagers, and college on suggesting this as a ‘good’ option for women, particularly for
students who have busy lives and do not want to worry about their adolescents who already struggle with impulse control. Fertility
contraception. They would rather have a LARC. Also, if they are awareness is the reason I and 3 of my 4 brothers and sisters are
coming in for contraception, they are planning on leaving with a here.’’ Female provider, age 56–60 years, North Carolina
method, not a calendar.’’ Female provider, age 36–40 years, New ‘‘I personally do not feel that I have had any successes with this method
York and frankly feel that this is a method best used by monogamous
individuals and families seeking pregnancy rather than pregnancy
Provider perceptions that FABMs are ineffective (n = 15) prevention.’’ Female provider, age 61–65 years, Missouri
‘‘I have no challenge about the method if someone chooses to use it. ‘‘None! Title X is going to be worthless now.’’ Female provider, age 41–
I have both a niece and nephew who were very much unplanned 45 years, Minnesota
using this method.’’ Female registered nurse, age 46–50 years,
Louisiana Not sure or no follow-up on FABM use among women counseled (n = 20)
‘‘There are other methods with more demonstrated effectiveness to ‘‘I make the referral, but do not know the outcome.’’ Female provider,
prevent pregnancy.’’ Female provider, age 55–60 years, Tennessee age 50–55 years, North Carolina
‘‘I consider it valuable at the bottom of the preferred option list— ‘‘I have only had two ask about it, as they did not want any hormones.
better than simple withdrawal and am biased as to the value of I have not seen them since their original evaluation. I am unsure if
more effective methods for most women.’’ Female provider, age they information we gave them helped.’’ Female provider, age 50–
51–55 years, Pennsylvania 55 years, Iowa
Provider education and training barriers (n = 33) Successful among certain ‘‘types’’ of women (n = 12)
‘‘Lack of education. I don’t feel I have enough training to give accurate ‘‘Where [I have seen success] has been in more traditional
information on all the different NFP methods.’’ Female registered communities with less frequent intercourse and supporting other
nurse, age 46–50 years, Montana traditions of abstinence.’’ Community outreach individual,
‘‘There is also no one here who has had formal training.although I Washington
would love to!’’ Female provider, age 26–30 years, North Dakota ‘‘People usually want something more reliable but it is great for
‘‘We have educational material to hand out to the patients, however ‘refugees’ or people who want no method and no further children.’’
no one in the facility is certified or specially trained on FABMs.’’ Female provider, age 66–70 years, Virginia
Female provider, age 51–55 years, Texas Success in improving body literacy (n = 10)
Provider time and scheduling barriers (n = 27) ‘‘I have had a few patients looking specifically for a FAM. The
‘‘No time for education because I have patients every 15 minutes and discussion increases awareness of their bodies and how they work
we get overbooks and walk-ins and can’t say no to late patients’’ which is always fabulous!’’ Female provider, age 41–45 years,
Female provider, age 41–45 years, Minnesota Arizona
‘‘Counseling takes more time than other methods.’’ Female provider, Patient satisfaction when utilized (n = 7)
age 61–65 years, Pennsylvania ‘‘Nearly everyone who chooses it, uses it for a long time (much longer
‘‘Time restraint during busy clinic to fully explain.’’ Female registered than hormonal methods other than IUDs and implant).’’ Female
nurse, age 36–40 years, Louisiana health counselor, age 46–50 years, California
Providers administrative/funding barriers (n = 9) ‘‘The few that follow this method are satisfied.’’ Female registered
‘‘It is not a tier 2 or tier 3 method of contraception. It is not nurse, age 31–35 years, Louisiana
recommended under Title X as a preferred pregnancy
prevention method. We do not have any written documents
explaining FABMs. There are no educational tools to show visual or pregnancy in conjunction with barrier methods and/or
kinesthetic learners.’’ Female health educator, age 21–25 years,
California mobile apps such as Cycle Beads (Standard Days meth-
‘‘Systems issues which do not support; FP funders will not accept this od), improved body literacy and fertility knowledge,
as a method in our EMR’’ Female provider, age 66–70 years, New
Jersey
and good outcomes with high satisfaction among
Perception of a lack of demand for FABMs (n = 21) women who were ‘‘self-motivated’’ (Table 4).
‘‘We have so many other more effective methods that patients aren’t
usually interested in FABMs.’’ Female provider, age 56–60 years,
Colorado
Discussion
In our knowledge, this is the first study to assess pro-
(continued) vider attitudes, knowledge, and behaviors on FABMs
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within the Title X network of providers in the United sider, for example, if they have a religious consider-
States. The low response rate should be noted and ation. Therefore, even these groups deserve to have a
data treated as a preliminary study. The findings of reliable source of information about FABMs. Perhaps
this study may not represent the views of the entire more importantly, FABMs have been used with typi-
Title X network of providers, especially as we think cal use pregnancy rates similar to those for hormonal
those who feel passionately about the topic (either pos- methods and barrier methods in several populations
itively or negatively) were more likely to respond than that were a point of concern among participants, in-
those who felt more neutral. It is also important to cluding low-literacy populations13–20 and young single
note that although FABMs are used widely interna- women with multiple partners.21–24 One small study in
tionally, this study is not representative of any global the midwest indicated that when women were educated
populations. about FABMs, more were interested in using them.6
Although a majority of providers had correct general Therefore, some of these provider barriers may reflect
knowledge of fertility, few providers demonstrated pos- misperceptions of the effectiveness of FABMs that
itive attitudes about offering FABMs as a viable option could be addressed through increased education and
for pregnancy prevention. Most reported neutral or training, as well as improved clinic materials.
negative perceptions about these methods, something FABM education for clinicians or patients should
that has been found in other studies,10,11 coupled stress the differences between the many modern meth-
with a common perception of these methods as ‘‘inef- ods. There are methods available that are designed to
fective’’ or inappropriate for their clients. This finding be simple and easy to use with little or no equipment
is similar to that found in previous studies in non- or supplies needed, some are complex and require
Title X providers, where a majority of clinicians under- some equipment, supplies, or technology, and all meth-
estimate the effectiveness of FABMs and do not always ods differ in their effectiveness of pregnancy preven-
provide all information about modern FABMs.6,7,10,11 tion.1 Some methods are not suitable for women
We found preliminary evidence to suggest that pro- with irregular menstrual cycles and some women
viders who had written materials around multiple may have preferences on the symptoms they check.
methods of FABMs were more likely to counsel clients All these aspects of the different FABMs should be
around FABM use. This may be due to increased con- taken into consideration when providing contraceptive
fidence among providers who had received resources to counseling to a patient who is interested in FABMs. In
provide these methods or a better understanding of addition, the differences between methods may dispel
FABM effectiveness data, but it could also be that pro- some beliefs that patients or providers have about
viders who were more likely to counsel about FABM FABMs if they view them as a whole, such as the belief
use were also more likely to have written materials that they are not effective or the belief that they require
about their use. too much equipment.
Our qualitative analyses identified significant pro- Clinicians reported providing verbal and written in-
vider barriers related to offering FABMs as a viable formation to clients who requested FABMs; however,
option for specific client populations, including those few clinics reported having training or education
with low health literacy, individuals who are single around FABMs onsite. Other studies have shown that
parenting, young people, and those who are facing medical students or residents are unlikely to include
challenging life circumstances. Patients with low health FABMs in curriculum or learning experiences.5,25,26
literacy may incorrectly identify their fertile window,12 Several providers noted a lack of time for FABM coun-
which is an opportunity for reproductive education seling within existing clinical schedules. This barrier
interventions. FABMs cannot be used effectively and mirrors a similar reported time barrier for other con-
should not be recommended in a relationship in traceptive services, including same-day insertions of
which timing of intercourse cannot be mutually de- intrauterine devices or vasectomy,27 and methods
cided upon and/or a barrier method cannot be used. such as Standard Days Method can be provided within
For women who have unique reproductive consider- the typical visit time frame, particularly if written ma-
ations (e.g., long cycles, anovulation, and breastfeed- terials are also available. Opportunities for improve-
ing), there is limited data about FABM effectiveness. ment may include the development of FABM clinical
However, even in some of these cases, an FABM trainings as CME-approved offerings, as providers are
may be the only method that a person would con- more engaged in learning new methods when they
Webb, et al.; Women’s Health Reports 2020, 1.1 361
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support their licensure requirements. In addition, the de- Additional research is needed to better understand
velopment of comprehensive written materials that pro- the acceptability of FABMs as contraception for both
vide an overview of multiple methods may improve providers and patients and determine best practices
both provider self-efficacy and increase clinical knowledge. in offering and counseling on FABMs in a family plan-
Recent studies have found that provider method bias is ning visit. Assessing the success of clinical interven-
common,28,29 but additional training on contraceptive tions to improve scheduling availability for same-day
shared decision making may be an opportunity to reduce services that include FABMs would provide valuable
bias against certain methods, such as FABMs.30 Table 5 insight into how these methods can be practically in-
includes some links to training and resources for clinicians corporated into the clinic offering. Other important
on FABMs. areas of future study include demonstrating whether
broader understanding of fertility information may
be helpful in health decision making and assessing
Table 5. Educational Resources for Fertility
Awareness-Based Methods whether emerging digital fertility applications lead to
increased options for those who desire to use FABMs.
Overviews on FABMs for clinicians Patient satisfaction and successful family planning
 Contraceptive Technology 21st Ed outcomes have been directly tied to increased avail-
B http://www. contraceptivetechnology.org/the-book/
ability of the full range of contraceptive methods.31
 World Health Organization’s medical eligibility criteria for
contraceptive use, 5th Ed
Incorporating FABMs into contraceptive counseling
B https://www.who.int/reproductivehealth/publications/family_ represents an opportunity to increase the contraceptive
planning/MEC-5/en/ offering for clients who want them. Despite existing
 Family Planning Handbook: A Global Handbook for Providers, ch 18,
2018
barriers to clinical provision, increasing demand for
B http://fphandbook.org/sites/default/files/global-handbook-2018- these methods, as well as recent federal interest in
full-web.pdf their availability, could support the development of
 Free webinars from the National Clinical Training Center for Family
Planning, supported by the U.S. Office of Population Affairs Title X
new strategies to incorporate FABMs more fully into
Family Planning Program, CE available contraceptive counseling.
B Understanding and Counseling Potential Users on Fertility
Awareness Based Methods for Pregnancy Prevention
j https://vimeo.com/264114233
Author Disclosure Statement
B Effectiveness of Fertility Awareness Based Methods for Pregnancy
Prevention A part of Dr. Rachel Peragallo Urrutia’s salary is paid
j https://vimeo.com/284453322 by Reply OB/GYN & Fertility, a company focused on
B Fertility Apps: A New Approach for Fertility Awareness Based
Methods
offering access to FABMs. No competing financial in-
j https://vimeo.com/277724852 terests exist for other authors.
Training for clinicians
Funding Information
 Standard Days method
B Online, free 1–2 hours training module, CME available
This research was funded by The Department of Health
B http://archive.irh.org/SDM_Training/index.php and Human Services, Office of the Assistant Secretary
 Two-Day Method of Health, Office of Population Affairs: Grant No. 5
B Overview and resources available
B http://irh.org/twoday-method/
FPTPA006029-01-00.
 Sensiplan (symptothermal method)
B Materials and training available at cost
References
j https://www.sensiplan-im-netz.de/?page_id=904
1. Urrutia RP, Polis CB, Jensen ET, Greene ME, Kennedy E, Stanford JB.
B In-person teacher training at Reply Ob/Gyn in 2021
Effectiveness of fertility awareness-based methods for pregnancy
j Contact [email protected]
prevention: A systematic review. Obstet Gynecol 2018;132:591–604.
B Sensiplan user manual and workbook available at cost
2. Daniels K, Abma JC. Current contraceptive status among women aged
j https://replyobgyn.com/store/product/sensiplan-physical-
15–49: United States, 2015–2017. NCHS Data Brief, 327. Hyattsville, MD:
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B https://www.marquette.edu/nursing/natural-family-planning- 6. Stanford JB, Thurman PB, Lemaire JC. Physicians’ knowledge and prac-
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9. SAS Institute Inc., Base SAS 9.4 Procedures Guide. Cary, NC: SAS Institute, dinal study. Hum Reprod 2007;22:1310–1319.
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Appendix A1
Appendix A1. Survey Questionnaire 3. Where is your primary clinic setting located?
(state or territory)
1. Does the clinic/service site where you work most
of the time (primary clinic setting) provide fam- 4. What is your age? (years)
ily planning services? 5. What is your current gender identity?
() Yes () Female
() No () Male
2. Does your primary clinic setting receive federal () Transgender male/trans man
Title X family planning funds? () Transgender female/trans woman
() Yes () Nonbinary, gender nonconforming, gender-
() No queer, genderless, or two-spirit
() Not sure () Prefer to self-describe
(Appendix continues /)
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6. What best describes your primary role at your 12. On average, how many patients do you see for
primary workplace/family planning setting? family planning services each week?
() Manager/administrator *The correct answer for the knowledge questions
() Clinical provider (NP, CNM, PA, MD, DO) below is denoted with an asterisk
() Registered nurse 13. Normal menstrual cycles are between 21 and 38
() Licensed vocational/practical nurse days in length.
() Health educator/counselor/health care associ- () True*
ate/medical assistant () False
() Community outreach staff 14. Ovulation is usually preceded by clear stretchy
() Billing/finance assistant vaginal discharge.
() Other () True*
7. What is your specialty/area of practice? () False
[] Adult medicine/internal medicine 15. Certain sexual positions can increase one’s
[] Family practice/family medicine chance of getting pregnant.
[] Infectious disease () True
[] Midwifery () False*
[] Ob/gyn 16. Ideally, intercourse should occur the day before
[] Women’s health or the day of ovulation for fertilization to occur.
[] Pediatrics () True*
[] Other () False
8. How many years has it been since you com- 17. Having intercourse more than once per day will
pleted your most advanced clinical training (res- increase the chance of conception.
idency, fellowship, etc.)? () True
9. How many years total have you been working () False*
at clinics/sites that provide family planning 18. Basal body temperature rises about half a degree
services? Fahrenheit after ovulation.
10. What are the principal settings in which you () True*
provide family planning services? () False
[] Health department (e.g., state, county, local) 19. Having intercourse three or more days after an
[] Hospital-based setting increase in basal body temperature increases
[] Planned parenthood the chance of conception.
[] Free-standing family planning organization () True
[] Community health center/federally qualified () False*
health center 20. Ovulation typically occurs *12–16 days before
[] Tribal health center menses.
[] University- or school-based setting () True*
[] Substance abuse treatment center () False
[] Faith-based organization/setting 21. Peak fertility for women occurs at what age?
[] Correctional facility-based setting () 23*
[] Federal government setting () 30
[] Private foundation or nonprofit setting () 35
[] Other () 40
11. Describe the area where your primary practice 22. What is the best predictor of difficulty in con-
site/clinic is located: ceiving?
() Urban () Age >35 years*
() Suburban () Low anti-Mullerian hormone level
() Rural () High follicle stimulating level
() Frontier () Body mass index 30 kg/m2 or higher
(Appendix continues /)
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23. Which of the following factors can increase a. What NFP/fertility awareness methods are in-
fertility? cluded in the written information you provide
() Use of water-soluble sexual lubricant patients?
() Living in a rural instead of urban environment [] Symptothermal (Sensiplan)
() Lying down for 10 minutes after intercourse [] Symptohormonal (Marquette)
() None of the above* [] The Billings Ovulation Method
24. Which of these factors places the woman at [] Two-Day Method
highest risk for infertility? [] Standard Days (Cycle Beads)
() Being >35 years* [] Natural Cycles
() Being under a lot of stress [] LAM (Lactational Amenorrhea Method)
() Smoking >10 cigarettes per day [] Other
() Having more than two alcoholic drinks per [] Unknown
day [] I provide her with information about modern
25. A 28-year-old woman desiring pregnancy FABM mobile applications
should consult a fertility/infertility specialist b. Which mobile apps do you recommend patients?
after a failure to become pregnant after how [] I refer her to a location that specializes in
many months of unprotected vaginal inter- FABM instruction
course? [] Other
() 3 months 30. Which of the following do you usually recom-
() 6 months mend as initial steps for a woman/couple who
() 12 months* are having difficulty achieving pregnancy, do
() 24 months not meet the definition of ‘‘infertility’’ and have
26. A 38-year-old woman desiring pregnancy had no previous evaluation for infertility?
should consult a fertility/infertility specialist [] Intercourse at least every other day during the
after a failure to become pregnant after how entire cycle
many months of unprotected vaginal inter- [] Intercourse during midcycle (i.e., cycle day
course? 10–16)
() 3 months [] Observation of cervical mucus and directed
() 6 months* intercourse to days with high-quality (fertile)
() 12 months mucus and a few days after
() 24 months [] Observation of basal body temperature and di-
27. How many times in the past month have you rected intercourse in the days leading up until
counseled a person/couple on FABMs/NFP the time of the temperature increase
planning for pregnancy prevention? [] Urine-based over-the-counter LH surge/ovu-
28. How many times in the past month have you lation test kits and intercourse on the day of
counseled a person/couple on FABMs/NFP to the LH surge
attempt to achieve pregnancy? [] Following advice from menstrual cycle track-
29. Which of the following best describes your re- ing or fertility tracking mobile applications
sponse when a patient asks you for information a. Please specify which specific mobile apps you
about FABMs for pregnancy prevention? recommend.
[] I tell her they do not work and recommend [] Other
something else 31. Does anyone at your facility have formal train-
[] I describe the use of the calendar method ing in FABMs?
[] I describe the use of the cervical mucus method () Yes
[] I describe the use of the basal body tempera- a. What best describes the primary role of those at
ture method your facility who have formal training in FABMs?
[] I provide her with written information on [] Manager/administrator
NFP/fertility awareness [] Clinical provider (NP, CNM, PA, MD, and DO)
(Appendix continues /)
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[] Registered nurse 32. In your clinic setting, would you say that as a
[] Licensed vocational/practical nurse method of contraception, FABMs/NFP is:
[] Health educator/counselor/health care associ- () 1—A nonviable option for most women
ate/medical assistant () 2
[] Community outreach staff () 3—Neutral
[] Billing/finance assistant () 4
[] Other () 5—A viable option for most women
b. Which FABMs have those at your facility been 33. Tell us about your personal or your clinic’s chal-
formally trained on? lenges with offering FABM as a method of
[] Symptothermal (Sensiplan) preventing pregnancy:
[] Symptohormonal (Marquette) 34. Tell us about your personal or your clinic’s chal-
[] The Billings Ovulation Method lenges with offering FABM as a method of
[] Two-Day Method achieving pregnancy:
[] Standard Days (Cycle Beads) 35. Tell us about your personal or your clinic’s
[] Natural Cycles successes with offering FABM as a method of
[] LAM (Lactational Amenorrhea Method) preventing pregnancy:
[] Other 36. Tell us about your personal or your clinic’s suc-
[] Unknown cesses with offering FABM as a method of
() No achieving pregnancy.

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