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Natural Family Planning as a Means of Preventing Pregnancy

Published: May 14, 2018

Introduction

Natural Family Planning (NFP) relies on the ability to track ovulation in order to prevent pregnancy. These methods predict fertile and unfertile days to identify when to avoid unprotected sex and are only used by a small fraction of women. Some women may choose to use these methods because they have a religious objection to contraception that involves drugs, devices, or surgical procedures. Others may use them because they prefer to use a hormone-free method. However, these methods are less effective than other forms of contraception such as the oral contraceptive pill, IUD, implant, and condoms.

Natural family planning has recently gained attention following the Trump Administration’s release of the 2018 Funding Opportunity Announcement (FOA) for the federal Title X family planning program. The updated FOA emphasizes abstinence and natural family planning methods, a major departure from prior administrations that have prioritized counseling women about the most effective methods. While NFP has always been included in the full range of contraceptive options offered to women seeking family planning care, some are concerned that the new emphasis on NFP in the Title X program will reduce already limited access to more effective and long-acting methods for low-income women who wish to use them. 1 This fact sheet provides an overview of Fertility Awareness Methods and their efficacy, reviews some of the new apps and natural family planning models, and discusses limitations as well as associated costs and insurance coverage of these methods.

Calendar-Based and Fertility Awareness-Based Methods

The average woman is fertile for a 6-day period each month — the 5 days before ovulation and the day of ovulation. Natural family planning methods use a combination of methods to help women identify these days. There are a range of tools including apps that have been developed to help women identify these fertile days ( Table 1 ). Women practicing NFP who want to prevent pregnancy may choose to remain abstinent during these fertile days or if they are not opposed to using a non-hormonal barrier method, may choose to use a condom.

Calendar-based methods, such as the Rhythm Method, track the menstrual cycle in order to identify the days a woman is most likely to become pregnant and are the oldest form of natural family planning. Fertility Awareness-Based Methods (FABMs) generally track changes in one or more signs of fertility associated with ovulation: basal body temperature, cervical mucus, hormone production, and cervical position, though they may also include calendar tracking as well. The basal body temperature method (BBT) requires a woman to take her temperature every morning immediately when she wakes up, before she gets out of bed, while the cervical mucus monitoring method requires her to track changes in vaginal discharge daily. Sympto-thermal methods track multiple signs, most typically the BBT method and the cervical mucus monitoring method, and is considered to be more effective than using only one of these methods. Other methods may also track hormone levels in the urine and changes in the position of cervix.

Breastfeeding may also be used as a method of contraception for postpartum women. Lactation amenorrhea is a temporary period of infertility immediately following the birth of a baby during which the hormones that produce breast milk prevent ovulation. In order to rely effectively on this method of contraception, a woman must exclusively and frequently breastfeed her baby for up to 6 months or until her period returns. This method will not work for women using a breast pump or formula.     

Use and Efficacy

Utilization of natural family planning methods in the United States is low. It is estimated that roughly 2% of sexually active women ages 15-44 used a natural family planning method in 2014. 2  Women may chose these methods because they are hormone-free, low cost, or for religious or personal reasons. The typical use effectiveness of NFP methods in preventing pregnancy depends on the accuracy of the method chosen, the ability of the woman to correctly interpret their biological signs of fertility, and the couple’s ability to avoid unprotected sex during the fertile window ( Table 2 ). With perfect use, clinical trials suggest NFP methods have very low failure rates. However, perfect use is hard to achieve. There is significant room for human error, and even just one miscalculation can lead to unintended pregnancy. In addition, many of the clinical trials measuring the efficacy of these methods have been criticized for their findings of low failure rates due to selection bias and non-representative samples. 3 One recent systematic review found that there are few studies evaluating the effectiveness of fertility awareness–based methods, and the existing studies are of moderate to low quality. As a group, NFP methods have a failure rate up to 25 pregnancies for every 100 women per year. 4 Lactation amenorrhea, however, is highly effective for roughly the 6-month period following childbirth, only if a women exclusively breastfeeds her infant and only for 6 months. In comparison, for every 100 women, less than one woman using an IUD or implant for a year, and roughly 5 to 9 women using oral contraceptive pills for a year, may become pregnant. 5

Limitations

Natural family planning methods can work to prevent pregnancy for some women. However, there are many limitations to these methods, making them less effective than most other hormonal and non-hormonal contraceptive options. NFP methods are time-intensive and require significant commitment from both the woman and her partner. Women are advised to track their cycles for at least 6 cycles to learn about their cycle length and signs of fertility before relying on this method to prevent pregnancy, leaving them vulnerable to unintended pregnancy if no other contraceptive method is used during this initial period. Women must also pay attention to signs of fertility such as vaginal discharge and temperature daily or multiple times a day, and correctly interpret their observations. Finally, the woman must be able to remain abstinent during the fertile window, which can last up to 12 days a month depending on the method, or use a barrier method.

Many women may not be good candidates for the use of NFP including women with multiple sexual partners and women with irregular cycles ( Text Box 1 ). Some methods, such as the calendar-based methods will not work for women with cycles shorter than 26 days or longer than 32 days. In addition, cycles and signs of fertility may vary for each woman, and even from month to month, due to a wide range of reasons including stress, sickness, sleep deprivation, use of certain medications and alcohol, making these methods less reliable. Finally, these methods do not protect again sexually transmitted infections.

Tools, Providers, and Instruction

Natural family planning methods require varying levels of training and technology to use correctly. For calendar-based methods, women may use a physical calendar or CycleBeads to track the days of their menstrual cycle. However, most methods now have mobile apps, including iCycleBeads. Some apps simply make it easier for women to log their biological fertility markers online. For example, Kindara, a fertility awareness app, even syncs with its own Bluetooth-enabled BBT thermometer, called the Wink, to track a woman’s temperature throughout her cycle. Other apps actually interpret these data to predict a women’s daily risk of pregnancy. Cycle Technologies, in partnership with the Institute for Reproductive Health at Georgetown University, is a prominent developer of natural family planning methods and mobile apps, including CycleBeads, the 2Day Method, and Dynamic Optimal Timing (DOT). DOT is currently undergoing an extensive efficacy study with funding from US Agency for International Development (USAID), with results expected in fall 2018.

Mobile health apps that are not considered medical devices do not require FDA approval for promotion and use in the United States. 6 Certain medical devices such as the Kindara Wink are classified as exempt from FDA review but must comply with general controls including registering with the FDA. No mobile health app has been approved by the FDA as a contraceptive device. One app, Natural Cycles, was certified in the EU as a contraceptive device in 2017, the first app to gain government approval. It operates by tracking a woman’s temperature and identifying the days on which women should use protection or abstain from sex.  Recently, Natural Cycles has come under scrutiny. Less than a year after its certification by the EU health agency, a Swedish hospital reported that 37 out of 668 women seeking abortions there between September and December 2017 had used Natural Cycles as their primary contraceptive method. 7 Nonetheless, in August 2018, this app was approved as a medical device by the FDA for use in the United States among women 18 years and older.   FABMs that track multiple signs of fertility sometimes require training with a licensed provider. There are organizations, many of them religiously-affiliated, dedicated to teaching and promoting these methods of natural family planning, such as the Couple to Couple League. Some of these groups have also developed their own model of natural family planning, such as the Creighton Model Fertilitycare System (CrMS), Sensiplan, and the Marquette Model, although these brands still rely on some variation or combination of temperature, cervical mucus, hormone, and cervical position tracking.

Insurance coverage and cost

FABMs are generally inexpensive to use. Basal body thermometers generally cost between $10 and $15, and most fertility awareness apps in the US are free. However, there are exceptions. The Kindara Wink thermometer costs $129, and the Natural Cycles app costs $80 a year. Some methods, such as the Creighton Model Fertilitycare System, require training from licensed providers and follow up visits that can cost anywhere from $100-$600 in total.

These instructional classes are not often covered by private insurance plans or Medicaid. A few state Medicaid programs will cover the cost of basal body thermometers, 8 and Washington will cover natural family planning education and supplies, including CycleBeads® and BBTs, for both women and men in their full scope Medicaid program as well as their family planning only program. 9 Iowa’s family planning expansion program also covers BBTs, 10 and Arizona, California, and Minnesota identify natural family planning services and education as a component of their programs. However, it is unclear whether plans would cover branded classes such as the Creighton Model Fertilitycare System. Some states, such as Illinois 11 and Minnesota, 12 require state-regulated private plans to cover natural family planning services without cost sharing.

Natural family planning has always been an element of programs and providers that offer comprehensive family planning services. Federal guidelines such as the CDC’s and the Office of Population Affairs’ Providing Quality Family Planning Services (QFP) and HRSA’s recommendations for preventive services for women clearly state that offering women the full range of FDA-approved contraceptive methods is a critical element of quality family planning care. In 2015, 82% of all clinics and 92% of Planned Parenthood clinics offered natural family planning instruction or supplies. 13 While new NFP models and apps have been developed to assist women to record and track signs of fertility in recent years, they require a commitment to daily and consistent use and dedication from both the woman and her partner(s). While natural family planning is an approach that some women may seek, many women are precluded from using these methods, and the vast majority of women in the US prefer to rely on more effective methods of contraception to avoid pregnancy. 14   For women who are precluded from using natural family planning methods or prefer to rely on other more effective contraceptive methods, easy access to the full range of FDA approved contraceptive methods is the most effective way for women to avoid unintended pregnancy.

Power to Decide. Power To Decide Raises Concerns About Title X Funding . February 2018.

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Kavanaugh ML, Jerman J. (2017).  Contraceptive method use in the United States: trends and characteristics between 2008, 2012 and 2014 . Contraception Journal.

Trussell J, Grummer-Strawn L. (1990). Contraceptive failure of the ovulation method of periodic abstinence . Family Planning Perspective ; 22(2):65-75.

Office of Population Affairs. Department of Health and Human Services. Natural Family Planning and Fertility Awareness Factsheet .

Office of Population Affairs. Department of Health and Human Services. Birth Control Methods .

Food and Drug Administration. Guidance for Industry and Food and Drug Administration Staff – Mobile Medical Applications . February 2015.

Ong, T. January 16, 2018. Contraceptive app hit with complaints after being blamed for 37 unwanted pregnancies . The Verge.

Kentucky, New York, Pennsylvania, Texas, Vermont, and Wisconsin.

Kaiser Family Foundation. (2013). Medicaid Coverage of Family Planning Services, results of a national survey report .

Washington Apply Health (Medicaid). (2018). Family Planning Billing Guide .

Iowa Department of Human Services. Family Planning Program .

Illinois 215 ILCS 5/356z.4

2017 Minnesota Statutes 62Q.14 Restrictions on Enrollee Services

Zolna MR, Frost JJ. (2015). Publicly funded family planning clinics in 2015: Patterns and trends in service delivery practices and protocols . Guttmacher Institute.

Lessard LN, Karasek D, et al. Contraceptive features preferred by women at high risk of unintended pregnancy. Perspectives in Sexual Reproductive Health. 2012 Sep;44(3):194-200

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Natural family planning may be an appealing birth control option if you can't or choose not to use other contraceptives.

Natural family planning is a method of birth control that helps you predict when ovulation will happen — and when you need to avoid unprotected sex if you don't want to conceive a child. This birth control method may involve charting your temperature daily, tracking changes in cervical mucus and paying attention to other key fertility indicators.

Another type of natural family planning is withdrawal, in which the penis is removed from the vagina before ejaculation to try to prevent pregnancy.

Natural family planning requires motivation, diligence and self-control. Natural family planning isn't as effective as other types of birth control, but it's inexpensive and doesn't have any side effects.

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Natural Family Planning

Affiliation.

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• PMID: 31536267
• Bookshelf ID: NBK546661

Natural family planning is the utilization of fertility awareness to either prevent or achieve pregnancy. In the United States, approximately 1% of women utilize natural family planning methods for contraception Worldwide, its use reaches about 3.6%. There are numerous options available to individuals and couples who desire family planning, and natural family planning is unique in that it can be utilized both as a conceptive and contraceptive option. As a contraceptive option, natural family planning has a typical failure rate of 24%

Copyright © 2024, StatPearls Publishing LLC.

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BRIAN A. SMOLEY, CDR, MC, USN, AND CHRISTA M. ROBINSON, LCDR, MC, USN

Am Fam Physician. 2012;86(10):924-928

Related editorials: Is Natural Family Planning a Highly Effective Method of Birth Control? Yes: Natural Family Planning is Highly Effective and Fulfilling and No: Family Natural Family Planning Methods Are Overrrated .

Related letter: Physicians Need More Education About Natural Family Planning

Patient information: See related handout on natural family planning , written by the authors of this article.

Author disclosure: No relevant financial affiliations to disclose.

Natural family planning methods provide a unique option for committed couples. Advantages include the lack of medical adverse effects and the opportunity for participants to learn about reproduction. Modern methods of natural family planning involve observation of biologic markers to identify fertile days in a woman's reproductive cycle. The timing of intercourse can be planned to achieve or avoid pregnancy based on the identified fertile period. The current evidence for effectiveness of natural family planning methods is limited to lower-quality clinical trials without control groups. Nevertheless, perfect use of these methods is reported to be at least 95 percent effective in preventing pregnancy. The effectiveness of typical use is 76 percent, which demonstrates that motivation and commitment to the method are essential for success. Depending on the method, couples can learn about natural family planning methods in a single office visit, through online instruction, or from certified instructors.

Family planning allows individuals and couples to anticipate and attain the desired number, spacing, and timing of children. 1 Fertility awareness methods of family planning use one or more biologic markers to identify fertile days of a woman's reproductive cycle. Intercourse is avoided or a contraceptive method is used on these fertile days to avoid pregnancy. Conversely, couples desiring pregnancy are more likely to conceive if they have intercourse during this fertile period. Fertility awareness methods qualify as natural family planning (NFP) if they are used with periodic abstinence rather than an artificial contraceptive method. 2 – 4

Although less than 1 percent of respondents to the 2006–2008 National Survey of Family Growth reported current use of NFP, 19 percent reported prior use of the rhythm method, and 5 percent reported prior use of some other NFP method. 5 If asked for family planning information, one-half of physicians report that they would provide information about NFP to prevent pregnancy, and three-fourths would provide information about its use to achieve pregnancy. 6 This article discusses methods, mechanisms of action, and demonstrated effectiveness of NFP to enable physicians to provide appropriate information and counseling to their patients.

Methods and Mechanisms of Action

The five principal types of NFP are calendar calculation, basal body temperature charting, cervical mucus monitoring, the symptothermal method, and lactational amenorrhea 4 ( Table 1 ) . The first four methods allow couples to plan intercourse around the days of increased fertility during the woman's reproductive cycle. In lactational amenorrhea, ovulation does not occur, and there are no fertile days. Use of this method is limited to women who are exclusively breastfeeding during the first six months postpartum, and applies only if menstruation has not resumed. When these conditions are met, lactational amenorrhea has been shown to be 92 to 100 percent effective. 4 , 7

Identification of the fertile period is the central focus of most NFP methods. In the days leading up to ovulation, estradiol from the maturing follicles stimulates the section of thin, stretchy, watery mucus in the cervical canal that facilitates sperm entry into the upper reproductive tract. Sperm can remain viable there for up to five days. Sperm entry is inhibited after ovulation by the secretion of thick, sticky cervical mucus stimulated by increasing progesterone levels. The ovum is capable of being fertilized for up to 24 hours after ovulation. The usual viability periods of sperm and ovum generate an average six-day fertile period that has been verified by empiric studies. 2 , 3 , 8

CALENDAR CALCULATIONS

Calendar methods of NFP are based on the relative consistency in the length of the luteal phase of the reproductive cycle. The rhythm method is the oldest NFP technique. The length of past cycles is used to predict the fertile period in the current cycle. The beginning of the fertile period is calculated by subtracting 18 days from the shortest of the previous six to 12 cycles. The end of the fertile period is calculated by subtracting 11 days from the longest cycle. For a woman with a perfectly consistent 28-day cycle, the rhythm method predicts an eight-day fertile period from days 10 through 17. Variations in cycle length increase the length of the predicted fertile period. 3 , 4 , 9 The Standard Days Method is a simplified calendar method that assumes a cycle length of 26 to 32 days and sets a 12-day fertile period from days 8 through 19. 10

BASAL BODY TEMPERATURE CHARTING

Basal body temperature charting takes advantage of the increase in a woman's temperature that occurs during the luteal phase of the reproductive cycle. An increase of at least 0.4°F (0.2°C) above the baseline temperature recorded early in the morning at the same time each day indicates that ovulation has occurred. This increase is monitored over three consecutive days, at which point the fertile period is considered over. Because basal body temperature charting does not identify the beginning of the fertile period, it is of limited use. Couples who desire pregnancy must use historical data to predict the next fertile period. Couples trying to avoid pregnancy must restrict intercourse to the luteal phase of the cycle. 3 , 4 , 9 Basal body temperature charting is typically used in combination with other methods.

CERVICAL MUCUS MONITORING

Cervical mucus monitoring has become the basis for most modern NFP methods. These methods allow users to identify the beginning and end of the fertile period by recognizing cyclical changes in the amount or consistency of cervical secretions. The Billings Ovulation Method, Creighton Model, and TwoDay Method are different systems for observing cervical secretions and using them as markers of fertility. The oldest of the three, the Billings Ovulation Method, is taught worldwide, and instructions are available online. 11 , 12 The Creighton Model is a standardized modification of the Billings Ovulation Method taught and personalized for couples over multiple sessions. 13 The TwoDay Method reduces the interpretation of cervical secretions to two questions: “Did I note secretions today?” and “Did I note secretions yesterday?” If a woman answers “yes” to either question, she is considered fertile. 14

SYMPTOTHERMAL METHOD

The symptothermal method combines calendar calculations, basal body temperature charting, and cervical mucus monitoring. Cervical secretions are the foundation for this method, and the other techniques provide a “double-check.” Women may use other signs (e.g., consistency and position of the cervix) or symptoms (e.g., breast tenderness, ovulatory pain) to aid in the identification of the fertile period. 15 , 16 The Marquette Model combines the use of an electronic hormonal fertility monitor to detect metabolites of estrogen and luteinizing hormone in the urine with observation of cervical secretions or basal body temperature charting to identify the fertile period. 2 , 17

Effectiveness of Modern NFP Methods

The effectiveness of family planning methods is measured for perfect and typical use. Perfect use failures represent failure of the method itself, whereas failures occurring during typical use include incorrect use. 18 The reported failure rates for modern NFP methods range from less than 1 to 5 percent for perfect use, and 2 to 25 percent for typical use. 16 , 19 – 30 The few randomized controlled trials of NFP methods have been limited by poor recruitment and high dropout rates. 31 Therefore, the evidence for NFP methods is based on observational trials that are prone to selection bias. Although many of these studies were conducted in emerging and developing countries, trials involving cervical mucus and symptothermal methods have been done in Europe and the United States. 16 , 20 – 24 However, the procedures used to measure and calculate effectiveness rates may overestimate the observed effectiveness. 18 Some trials have provided a more direct accounting of method failures and used preferred statistical techniques to determine failure rates. 16 , 19 , 25 , 28 , 30 A comparison of NFP methods is provided in Table 2 . 7 , 16 , 19 – 30

Patient Counseling

NFP methods have unique benefits and important limitations. One benefit for patients is an enhanced understanding of the reproductive process. This knowledge empowers couples to manage their reproductive lives without medical intervention. By routinely observing biologic markers, women may detect medical problems and bring them to the attention of their physician earlier than might otherwise occur. All NFP methods encourage couples to engage in a shared discussion about sexual activity and reproduction. Finally, because these methods do not require pharmaceutical or procedural intervention, they have no medical adverse effects. 3 , 9

The limitations of NFP are related to the requirement of periodic abstinence. As evidenced by the relatively high failure rates with typical use, some couples may not be able to do this. All NFP methods can, to varying degrees, overestimate the fertile period and require longer periods of abstinence than might otherwise be needed. 2 Additionally, illness, disrupted sleep, and the use of medications can alter or interfere with the observation and interpretation of some biologic markers. 4 The monitoring of fertility hormones in urine may provide NFP users with a more objective, specific, and reliable marker of the fertile period. 2

Despite challenges, NFP methods are a viable and effective family planning option for motivated patients, and may be the ideal option for some. Interested couples require instruction in their chosen method. The Standard Days and TwoDay methods can be taught during an office visit. 32 If this is not practical, or if couples are interested in other methods, several organizations provide detailed information and instruction ( Table 3 ) .

The American Academy of Family Physicians' policy statement on providing advice about contraception is available at https://www.aafp.org/about/policies/all/contraceptive.html .

Data Sources: We used search results from Essential Evidence Plus, the Cochrane Database of Systematic Reviews, the National Guideline Clearinghouse, and PubMed citations. Key terms included condoms, contraception, contraceptives, oral, intrauterine devices, family planning, and natural family planning. Last search date: September 17, 2011.

World Health Organization. Health topics: family planning. http://www.who.int/topics/family_planning/en/ . Accessed September 12, 2011.

Fehring RJ. Efficacy and efficiency in natural family planning services. Linacre Q. 2009;76(1):9-24.

Jennings VH, Arevalo M. Fertility awareness-based methods. In: Hatcher RA, Trussell J, Nelson AL, Cates W Jr., Stewart FH, Kowal D, eds. Contraceptive Technology . 19th ed. New York, NY: Ardent Media; 2008:343–360.

American College of Obstetricians and Gynecologists ACOG patient education: natural family planning . Washington DC: ACOG; 2003.

Mosher WD, Jones J. Use of contraception in the United States: 1982–2008. Vital Health Stat 23. 2010(29):1-44.

Choi J, Chan S, Wiebe E. Natural family planning: physicians' knowledge, attitudes, and practice. J Obstet Gynaecol Can. 2010;32(7):673-678.

Van der Wijden C, Kleijnen J, Van den Berk T. Lactational amenorrhea for family planning. Cochrane Database Syst Rev. ;2003(4):CD001329.

Wilcox AJ, Weinberg CR, Baird DD. Timing of sexual intercourse in relation to ovulation. Effects on the probability of conception, survival of the pregnancy, and sex of the baby. N Engl J Med. 1995;333(23):1517-1521.

Pallone SR, Bergus GR. Fertility awareness-based methods: another option for family planning [published correction appears in J Am Board Fam Med . 2009;22(5):596]. J Am Board Fam Med. 2009;22(2):147-157.

Georgetown University Institute for Reproductive Health. About SDM. http://www.irh.org/?q=content/standard-days-method-sdm . Accessed September 12, 2011.

BOMA-USA. http://www.boma-usa.org . Accessed September 12, 2011.

Ovulation Method Research and Reference Centre of Australia. Billings ovulation method. http://www.woomb.org/bom/index.html. Accessed September 12, 2011.

Pope Paul VI Institute for the Study of Human Reproduction. Creighton Model FertilityCare system. http://www.creightonmodel.com . Accessed September 12, 2011.

Georgetown University Institute for Reproductive Health. About TwoDay Method. http://www.irh.org/?q=content/twoday-method . Accessed September 12, 2011.

The Couple to Couple League. Sympto-thermal method of NFP. http://ccli.org/nfp/stm-method/index.php . Accessed September 12, 2011.

Frank-Herrmann P, Heil J, Gnoth C, et al. The effectiveness of a fertility awareness based method to avoid pregnancy in relation to a couple's sexual behaviour during the fertile time: a prospective longitudinal study. Hum Reprod. 2007;22(5):1310-1319.

Marquette University. Natural family planning. http://nfp.marquette.edu . Accessed September 12, 2011.

Lamprecht V, Trussell J. Natural family planning effectiveness: evaluating published reports. Adv Contracept. 1997;13(2–3):155-165.

Trussell J. Contraceptive failure in the United States. Contraception. 2011;83(5):397-404.

Fehring RJ, Schneider M, Barron ML. Efficacy of the Marquette Method of natural family planning. MCN Am J Matern Child Nurs. 2008;33(6):348-354.

Fehring RJ, Schneider M, Raviele K, Barron ML. Efficacy of cervical mucus observations plus electronic hormonal fertility monitoring as a method of natural family planning. J Obstet Gynecol Neonatal Nurs. 2007;36(2):152-160.

European multicenter study of natural family planning (1989–1995): efficacy and drop-out. The European Natural Family Planning Study Groups. Adv Contracept. 1999;15(1):69-83.

Hilgers TW, Stanford JB. Creighton Model NaProEducation Technology for avoiding pregnancy. Use effectiveness. J Reprod Med. 1998;43(6):495-502.

Rice FJ, Lanctôt CA, Garcia-Devesa C. Effectiveness of the sympto-thermal method of natural family planning: an international study. Int J Fertil. 1981;26(3):222-230.

Arévalo M, Jennings V, Sinai I. Efficacy of a new method of family planning: the Standard Days Method. Contraception. 2002;65(5):333-338.

Gribble JN, Lundgren RI, Velasquez C, Anastasi EE. Being strategic about contraceptive introduction: the experience of the Standard Days Method. Contraception. 2008;77(3):147-154.

U.S. Agency for International Development, George-town University Institute for Reproductive Health. Long-term use of standard days method: experience of operations research study participants. http://pdf.usaid.gov/pdf_docs/PNADL887.pdf . Accessed April 26, 2012.

Trussell J, Grummer-Strawn L. Further analysis of contraceptive failure of the ovulation method. Am J Obstet Gynecol. 1991;165(6 pt 2):2054-2059.

Thapa S, Wonga MV, Lampe PG, Pietojo H, Soejoenoes A. Efficacy of three variations of periodic abstinence for family planning in Indonesia. Stud Fam Plann. 1990;21(6):327-334.

Arévalo M, Jennings V, Nikula M, Sinai I. Efficacy of the new TwoDay Method of family planning. Fertil Steril. 2004;82(4):885-892.

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Natural Family Planning

Frequently asked questions.

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Sometimes myths can teach the good as in stories where virtues are learned. And, other times myths can cause harm since they distort reality. In NFP education we find that several misconceptions regarding the principles and practice of NFP continue to exist. On this page, we provide information to bust the myths!

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Please note, the USCCB provides this content in a brochure for purchase. Please see below to order. For a more detailed overview of the philosophy, science, and method categories of NFP, read the Introduction to NFP.

Natural Family Planning Myth & Reality

Myth #1: nfp is based on guesswork: it's what people used before modern science developed contraception..

Natural Family Planning (NFP) is not based on folktales!

NFP is a general title for the methods of family planning that are science-based, accurate, natural, healthy, reliable, and moral. There are many NFP methods and all can be used to achieve, or to postpone, a pregnancy  naturally . NFP is based on scientific research about women's cycles of fertility. Over a century ago, scientists discovered cyclic changes in cervical mucus and their relation to ovulation. In the 1920s, scientists identified the temperature rise that signals ovulation. But it wasn't until the 1950s, that scientists developed programs to teach others how to observe and interpret these fertility signs. NFP methods are grouped according to which signs of fertility are being observed and charted. They are as follows: the basal body temperature method (BBT) monitors changes in a woman's temperature when she wakes up each morning; the cervical mucus method ( more commonly called "Ovulation Method" or "OM") monitors changes in a woman's cervical mucus; the Sympto-Thermal Method (STM) combines observations of temperature and cervical mucus with other indicators, such as changes in the cervix and secondary fertility signs; and the Sympto-Hormonal Method (SHM), which is similar to the STM, includes the self-detection of reproductive hormones in the urine with the assistance of an ovulation predictor kit or fertility monitor.

Myth #2: NFP can be used only by women with regular cycles.

NFP works with menstrual cycles of any length and any degree of irregularity. NFP does not depend on a woman having regular menstrual cycles. NFP treats each woman and each cycle as unique. These methods rely on daily observations of the woman's signs of fertility. NFP can be used during breastfeeding, just before menopause, and in other special circumstances. NFP allows a woman to understand the physical signals her body gives her to tell her when she is most likely to become pregnant (around the time of ovulation). Once the woman understands this information, she and her husband can use the information according to their family planning intentions (i.e., to either achieve or postpone pregnancy). Instruction in NFP provides women with information about their bodies that is specific and observable. The natural methods can be used throughout a woman's reproductive life. These methods teach couples to monitor current, daily fertility signs of the woman's menstrual cycle. When special circumstances occur, (e.g., stress, illness, breastfeeding, post-miscarriage, perimenopause, etc.), NFP instructors can provide additional guidance in interpreting signs of fertility.

Myth #3: NFP is too complicated to be used by most people.

NFP can be used by anyone who learns the method and is motivated to apply the guidelines. NFP information is easy to learn. In fact, the methods have been successfully adapted to suit the needs of people and cultures all around the world. The key to using NFP effectively is for couples to  learn together  the information about their combined fertility, and to  change their behavior , applying the guidelines according to whether they wish to achieve or postpone pregnancy. This process is learned in NFP education, where the couple can practice observing and charting the wife's signs of fertility. This is not hard to learn but will take effort. NFP couples say that NFP is worth the effort because many benefits will be gained, including stronger communication, mutual responsibility, and greater respect for each other.

Myth #4: NFP is not a reliable method of family planning.

NFP is not only reliable, but it is the only  authentic  method of family planning. Since NFP methods are not contraception, their effectiveness works both ways—for achieving and postponing pregnancy. When couples wish to achieve a pregnancy they can time sexual intercourse to the fertile window of the menstrual cycle, thereby optimizing the possibility of becoming pregnant. When wishing to avoid pregnancy, studies show that couples who follow their NFP method's guidelines correctly, and all the time, achieve effectiveness rates of 97-99%. Others, who are unclear about their family planning intention (i.e., spacing or limiting pregnancy) or are less motivated, will not consistently follow the method's guidelines and have a lower effectiveness rate of 80-90%. Effectiveness of Natural Family Planning in Avoiding Pregnancy

• Couples who carefully follow all the rules for avoiding pregnancy all the time: 97%-99%
• Couples who do  not  follow all the rules for avoiding pregnancy all the time: 80%-90%

*Note: these percentages represent the range of effectiveness provided by NFP studies. They are based on the number of pregnancies among 100 couples in one year of NFP method use.

Myth #5: There is no difference between NFP and contraception.

NFP methods are different from and better than contraception. NFP methods:

• have no harmful side effects
• are environmentally friendly
• are virtually cost-free
• cooperate with, rather than suppress, a couple's fertility
• can be used both to achieve and avoid pregnancy
• call for shared responsibility and cooperation by husband and wife
• require mutual communication
• foster respect for and acceptance of the total person
• encourage maturity and the virtue of chastity
• value the child
• honor and safeguard the unitive and procreative meanings of married love.

In other words, there is a big difference between NFP and contraception. NFP, as opposed to contraception, does not deliberately frustrate the procreative potential of sex. So, NFP is morally acceptable while contraception is actually sinful and never morally right. NFP is unique because it enables its users to work with the body rather than against it. Fertility is viewed as a gift and reality to live, not a problem to be solved. Ultimately, NFP respects God's design for married love.

Myth #6: NFP does not allow for sexual spontaneity.

Most of the time, "spontaneity" in sex is itself a myth! Modern culture is awash in sexual messages. This may fool us into thinking that "everyone" is having sex as often as possible and always "spontaneously!" Even married couples may fall into this trap. Or, they may think that their sex lives would be more spontaneous "if only" their spouse wanted sex at the same time they did. The reality is that most marital sexual encounters are planned, or at least happen in situations favorable to love-making that are set up by agreement regardless of the family planning method used. Otherwise, in the press of daily life with jobs, household chores, social commitments, children's demands, etc., a husband and wife would rarely have sex! It's not necessarily bad news that married couples often plan on a time to have sexual relations. A loving invitation given in advance means a time of healthy anticipation for both husband and wife. For NFP couples who are trying to postpone a pregnancy, such an invitation in the days of sexual abstinence can mean living a "chaste courtship" that will be followed by a "mini-honeymoon." NFP couples often talk about how the times of sexual abstinence have helped them deepen their expressions of love for each other through loving gestures, "date nights," significant conversations, and so forth. This is not to say that the times of abstinence are not challenging. They can be! With a positive attitude and living through it together, husband and wife can use periodic sexual abstinence to grow individually and as a couple. Such self-mastery fosters authentic freedom where one's desires are put in service to the other—a necessary ingredient for marriage! Real sexual spontaneity depends upon real freedom—and NFP fosters such freedom.

Myth #7: Couples who use NFP have sex less often than couples who use contraception.

The frequency of sexual intercourse is based on a couple's intention and desire, not on the family planning method. NFP couples have sex as much as other married couples. They just have it on a different schedule according to whether they wish to avoid pregnancy or not. When spacing births, they would abstain from sexual intercourse during the fertile time of the woman's menstrual cycle. Keeping in mind that every woman is unique and every cycle is unique, the days of sexual abstinence will vary. But it's important to ask if the "frequency" of sexual intercourse is the right measure of fulfillment in a marital relationship. Most married couples would say that it is more important for their sexual relationship to reflect the quality of their marriage, that is, healthy, loving, intimate, and respectful. NFP can be a great help to couples who are interested in building a strong marriage because NFP supports the gift of one's spouse, the gift of life, and God's design for married love!

Myth #8: The Catholic Church wants people to have as many babies as possible.

In fact, the Catholic Church encourages people to be both generous and responsible stewards over their fertility. In this view of "responsible parenthood" married couples carefully think about the just reasons they may have to postpone pregnancy. When making decisions about the number and spacing of children in their family, they weigh their responsibilities to God, each other, the children they already have, and the world in which they live. Responsible parenthood is lived within the structures that God has established in human nature. The nature of sexual intercourse, which is both life-giving (procreative) and love-giving (unitive), reflects a Divine plan. That is why the Church teaches that husband and wife must not actively intervene to separate their fertility from their bodily union. NFP methods respect the Divine plan and are at the service of authentic married love.

Myth #9: The Catholic Church does not want married couples to have sex just for pleasure.

The Catholic Church wants married couples to have the best sex possible! Sexual pleasure in marriage is good. Pleasure is a part of intercourse, however, not its sole focus. There is, after all, a difference between simply "having sex," which includes actions aimed at one's own pleasure, and "making love," which involves giving oneself to another. Put another way, there is a difference between "self-taking" and "self-giving." "Making love" as God planned it for marriage, means that husband and wife offer themselves to each other as a gift. This sexual gift is faithful and exclusive. It rejoices in the other person, is respectful of God's design, and welcomes a child who may come from their union. It thus has the potential to build the family. In expressing the mutual love and commitments of husband and wife, sexual intercourse becomes a lasting source of joy in their marital relationship.

________________

The above questions with their answers are available in a brochure called "NFP, Myth and Reality," (English and Spanish). To order, contact: [email protected] ; or call toll free at 1-866-582-0943. Ask for publication #9522 for English and #9523 for Spanish. Also available to order via the USCCB Store .

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In spite of new developments in contraceptive practice, the world population has not been brought under control. It is estimated that by 2025 the global population could nearly double, to about 8.3 billion. This presentation will review the different methods of natural family planning and future trends of developments.

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Schenker, J.G., Mor-Yosef, S. (1985). Natural family planning. In: Runnebaum, B., Rabe, T., Kiesel, L. (eds) Future Aspects in Contraception. Springer, Dordrecht. https://doi.org/10.1007/978-94-009-4916-4_1

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• v.85(4); 2018 Nov

The State of the Science of Natural Family Planning Fifty Years after Humane Vitae : A Report from NFP Scientists’ Meeting Held at the US Conference of Catholic Bishops, April 4, 2018

Michael d. manhart.

1 Couple to Couple League, Cincinnati, OH, USA

Richard J. Fehring

2 College of Nursing, Institute for Natural Family Planning, Marquette University, Milwaukee, WI, USA

A one-day meeting of physicians, professional nurses, and scientists actively involved in Natural Family Planning (NFP) research was held to review the state of the science of NFP and consider future priorities. The meeting had four objectives: (i) determine the gaps in research evidence for secure methods of NFP among women of all reproductive categories, (ii) determine the gaps in the research and development of new technology for providing NFP services, (iii) determine the gaps in the research that determine the benefits and challenges with use of NFP among married couples, and (iv) provide prioritized ideas for future research needs from the analysis of evidence gaps from objectives above. This article summarizes the discussion and conclusions drawn from topics reviewed. While much has been accomplished in the fifty years since Humane vitae , there are still many gaps to address. Five areas for future research in NFP were identified as high priority: (1) well-designed method effectiveness studies among various reproductive categories including important subpopulations (postpartum, perimenopause, posthormonal contraceptive), normally cycling women (especially US women), and comparative studies between NFP methods; (2) validation studies to establish the benefit of charting fertility signs (both currently known and potential new indicators) as a screening tool for women’s health issues; (3) ongoing independent evaluation of fertility monitoring apps to provide users perspective on the relative merits of each and to identify those most worthy of further effectiveness testing; (4) studies evaluating the impact of new technologies on NFP adoption, use, and persistence; and (5) creation of a shared database across various NFP methods to collaborate on shared research interests, longitudinal studies, and so on.

This summarizes a meeting to review the scientific and medical progress related to natural family planning made in the 50 years since Humane Vitae and to define priorities for future work. Areas reviewed included the evidence for avoiding pregnancy in normally cycling, postpartum, and perimenopausal women, the impact of new technology, including fertility charting apps, on NFP, and the impact on relationships and personal well-being from use of NFP. Five priority focus areas for future research were also identified.

Introduction

A symposium celebrating the fiftieth anniversary of the encyclical Humane Vitae at the Catholic University of America in April 2018 provided the opportunity to hold a one-day meeting of physicians, professional nurses, and scientists actively involved in Natural Family Planning (NFP) research to review the state of the science of NFP and consider future priorities. Supported by the NFP program of the US Conference of Catholic Bishops (USCCB), Marquette University College of Nursing Institute for NFP, the Couple to Couple League, and anonymous donors, the meeting was based on the call of Pope Paul VI (1968) in Humanae vitae for scientists to develop more secure methods of NFP and for delineating the best conditions for their use. The meeting had four objectives:

• Determine the gaps in research evidence for secure (i.e., evidence-based effective) methods of NFP among women of all reproductive categories.
• Determine the gaps in the research and development of new technology for providing NFP services.
• Determine the gaps in the research that determine the benefits and challenges with use of NFP among married couples.
• Provide prioritized ideas for future research needs from the analysis of evidence gaps from objectives above.

This meeting was also inspired by a similar gathering of NFP researchers and educators held in Canada in 2016 under the leadership of the International Institute for Restorative Reproductive Medicine. That event brought together experts with a diversity of perspectives and yielded valuable insights that underscored the benefits of collaboration in a field of research that is traditionally underfunded and generally disregarded in family planning programs. This meeting built on the groundwork laid in Canada.

The following is a summary of the information and discussions from the April meeting along with the results of an exercise intended to focus attention on those areas in highest need of future work. Our hope is that by sharing this summary, more investigators will be motivated to continue to conduct and publish research on NFP and its impact on marriage and family life.

Current State and Gaps in the Evidence for NFP When Used to Postpone Pregnancy

Systematic reviews of the effectiveness of NFP when used to postpone pregnancy are rare. Grimes et al. (2005) examined only randomized controlled studies and found two, each with serious methodological flaws. He concluded that the comparative efficacy of these methods remains unknown but suggested that, based on these flawed studies, unintended pregnancy rates are high using NFP. Manhart et al. (2013) reviewed English-language studies published since 1980 and concluded that each of the major methods has at least one high-quality prospective cohort study based on the criteria developed and employed by the authors using Strength of Recommendation Taxonomy (SORT; Ebell et al. 2004 ). Those studies meeting the high-quality standard had typical unintended pregnancy rates ranging from less than five to twenty-two per 100 women over twelve months of use and perfect use rates of less than five per 100 women over twelve months of use.

A more recently completed comprehensive review was presented at the meeting ( Urrutia et al. 2018 ). The protocol for the review is available through PROSPERO, the International Prospective Register of Systematic Reviews (CRD42015017760, accessible at http://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=17760&VersionID=31281 ). The multidisciplinary team undertaking the review included a wide spectrum of attitudes, from NFP-only to pro-contraceptive scientists. The review included all studies published as of June 2017 in English, French, Spanish, or German that prospectively evaluated a specific method of NFP for at least one year when used to avoid pregnancy. A total of fifty-one unique papers were identified that met the screening criteria, reflecting the paucity of research on NFP in general. These studies were independently reviewed by two authors, and a consensus quality rating was obtained.

When evaluated by the quality metrics developed for this review, no high-quality studies were identified, twenty-one studies were of moderate quality, and thirty were judged low quality. Possible differences between the criteria used for a study to be considered high quality by Manhart et al. (2013) and Urrutia et al. (2018) were discussed. For the latter, a greater emphasis on articulation of the inclusion/exclusion criteria, lower levels of lost-to-follow-up, exclusion from analysis of any cycles where no sexual activity occurred, and inclusion of specific subpopulation analysis were required to be defined as high quality.

Whether or not studies used to support the approval and use of hormonal contraceptives, devices, or barriers would be scored as high quality by this scheme was acknowledged as an unknown at this time. Dumitru, Gilbride, and Duane (2016) compared the quality of studies of oral contraceptives published since 2000 to the quality of studies of fertility awareness–based methods (FABMs) using the SORT criteria and concluded that five of the forty-seven (11 percent) oral contraceptive studies met the high-quality standard, while ten of the thirty (30 percent) FABM studies published since 1980 met the high-quality standard. The Dumitru review underscores that Urrutia et al.’s (2018) finding that there are no high-quality NFP studies is not necessarily worse than the status among the contraceptive literature.

Among the various methods, the Sensiplan Sympto-Thermal Method (STM) and Marquette (urinary hormone only) Method had the lowest typical unintended pregnancy rates (both less than five per 100-women years), while the other methods had typical unintended pregnancy rates ranging from ten to thirty-three per 100-women years. Perfect use was similar with Sensiplan and Marquette, both less than one per 100-women years unintended pregnancy rates, and the other methods had rates generally less than five per 100-women years.

The discussion of the systematic reviews also focused on the heterogeneity of the concept of unintended pregnancy. Stanford et al. (2000) demonstrated that in the National Survey of Family Growth, unintended pregnancies cover an extremely wide range of actual circumstances when the respondents’ own words are used—from hardly unexpected (“The pregnancy came a few months earlier than expected”) to clearly unexpected and unwanted (“I don’t want it and am getting rid of it”).

In the context of NFP, where couples are fully aware of when conception is a distinct probability and the methods are used to achieve as well as avoid pregnancy, unintended pregnancy is a far more complex concept than can be expressed as a single statistical number. Recognizing the complexity and multifaceted meaning of “unintended pregnancy,” the Urrutia et al. (2018) group plans future work focused on the evidence for impact of relationship factors, motivation, sexual behavior, demographics, breastfeeding, and other reproductive factors on unintended pregnancy rates.

The group concluded that more research is needed on all methods when used to postpone pregnancy. Future studies need to integrate the learning from the past decades to assure high-quality study results. The lack of information on use of most methods among US users is a notable outage. Finally, the inclusion of all pregnancies, both intended and unintended, will increase transparency of reporting and help others judge overall effectiveness.

Nevertheless, providers should not shy away from recommending effective NFP methods due to gaps in the current knowledge. Similar gaps have not prevented manufacturers and medical organizations from promoting widespread use of contraceptives. In addition, it is well-documented that women who use hormonal contraception, particularly oral contraceptives, often stop using it due to side effects and then as a result get pregnant; yet this pregnancy is not counted as a failure of the contraceptive. In addition, research shows that women prefer methods that are safe (i.e., no side effects), and NFP has a clear advantage over the alternatives here ( He et al. 2017 ; Jackson et al. 2016 ).

Evidence for Effectiveness of NFP When Used in Special Circumstances

Nfp effectiveness when used in postpartum breastfeeding transition.

The postpartum transition, defined as the time between the birth of the baby and the return of regular menstruation, is a time when many users of NFP are particularly concerned about an unexpected pregnancy. The length of this transition is variable and is highly influenced by feeding patterns of the child (exclusive and continued nursing can significantly delay the return of ovulation) and the mother’s own physiology.

Unfortunately, there is a paucity of high-quality data regarding NFP effectiveness in this period. Only ten studies were identified for this review; nine were a prospective cohort design, and one was a retrospective cohort trial. Nine of the trials used six or twelve months as a time-based end point, and only one used return of the menstrual cycle as the end point. Calculations using months of use instead of cycles can overestimate effectiveness rates since postpartum amenorrhea is a single cycle with highly variable lengths. Further complicating comparison, cervical mucus is often subjectively defined and thus not comparable across studies.

Several challenges with using NFP methods when postpartum were discussed. First, cervical mucus is sometimes a poor indicator of fertility in this transition. Some users experience intermittent patches of peak type mucus due to high estrogen from an active follicle that is not progressing toward ovulation, adding uncertainty and extended periods of abstinence; postpartum breastfeeding women often have continuous mucus patterns that make it difficult to define a basic infertile pattern; finally, arousal fluid can also look like peak type mucus, confusing some users. Second, basal body temperature when used alone in the transition is inconvenient for mothers with nursing babies and not specific in identifying the infertile time prior to the initial postpartum ovulation. Recognizing these difficulties, most NFP methods have postpartum algorithms that are complex and require long periods of abstinence, which in many cases are likely longer than necessary. The lactational amenorrhea method (LAM) is a short-term method of NFP that applies to exclusively breastfeeding women and is reported to be highly effective in the first six months postpartum. It, too, has limitations, most notably the definition of “exclusive” breastfeeding which was found to vary across studies and the low percentage of women that meet the criteria through the first six months postpartum.

Reported typical unintended pregnancy rates of mucus-only NFP methods used postpartum are nineteen to twenty-four per 100 women over twelve months of use. The STM, used postpartum, has been characterized as highly sensitive but not specific; it detects 77–94 percent of potentially fertile days (high sensitivity) but calls for abstinence on about half the days when women were not fertile based on direct hormonal measurements (low specificity; Kennedy et al. 1995 ). More recently, Bouchard, Fehring, and Schneider (2013) reported that urinary hormone monitoring using the Marquette Model postpartum protocol yielded eight unintended pregnancies per 100-women years with typical use and two per 100-women years with correct use.

The advent of at-home urinary hormone detection (including estrogen, luteinizing hormone [LH], and progesterone [PdG] metabolites) provides an opportunity to significantly improve our understanding on how to help women manage this transition as these tests may provide a less subjective approach to determining daily fertility status and potentially reduce unnecessary abstinence. For example, a woman using LAM who experiences an interim bleed might determine with hormone detection that it reflects estrogenic breakthrough bleeding activity that is not rapidly progressing toward an ovulatory event and therefore would not be excluded from continuing LAM.

The group concluded that more studies of NFP in the postpartum transition period are needed. In addition, NFP protocols that are less complex and less subject to user misinterpretation would be important improvements. With increasing accessibility to in-home hormonal monitoring and ability of mobile devices to bring complex computing power directly to users, the technology for improved protocols appears to be in place. What is needed are high-quality effectiveness studies with unintended pregnancy as an outcome employing these latest advances, ideally in comparison to traditional NFP postpartum protocols.

NFP effectiveness in older women

The Staging of Reproductive Aging Workshop Model (STRAW) proposes an objective measure for the beginning of perimenopause—a persistent difference of seven days or more in the length of consecutive cycles, with persistence defined as recurrence of this difference within ten cycles of the initial event ( Harlow et al, 2012 ). Secondary indicators include low levels of Anti-Müllerian hormone and inhibin B and variable to elevated levels of follicle-stimulating hormone (FSH) when measured on cycle days two to five. Vasomotor symptoms often appear at the later stages of perimenopause.

Changes in reproductive capacity occur prior to perimenopause: ovarian egg supply is diminished significantly at around age thirty-five and after forty-two may be down to less than fifty. Further, the remaining eggs, and sperm of men over thirty-five, have a higher proportion of frayed chromosomal ends. This chromosome damage may result in conceptions that lead to early pregnancy loss, most likely completely undetected. In addition, NFP users and those who track their cycles may notice subtle changes in both menstrual and cycle patterns as they move into their midthirties.

For many (but not all) couples, pregnancy in their early forties can bring serious concerns including possible health problems that can occur with pregnancy at older age, the challenges of raising their current children, and the deep-seated belief that their family is “complete.”

An important factor in this transition is the likelihood of pregnancy in the absolute. Previous studies in Israel indicate a pregnancy rate of only 0.2 percent among women over forty-five, and population-based studies where contraception was never used indicate live births cease by age forty-two to forty-three. In contrast, other studies show a reasonable proportion of women are still ovulating in their forties. A World Health Organization (1994) study of menopause indicated that at age forty-five, fertility is about 10 percent of maximal and by age fifty is reduced to 1 percent of maximal. However, the study also indicated that use of NFP during perimenopause would be difficult because of the variability of the menstrual cycle. Thus, while the probability of pregnancy is low for women in their forties, it is not zero.

Regarding the evidence for NFP use in this transition period, there are fewer studies of NFP in this cohort than found in postpartum women. Fehring and Mu (2014) examined 160 women aged forty to fifty-five who were using online or in-person NFP instruction. An additional cohort has supplemented this to yield a total cohort of 206 perimenopausal women. No pregnancies were observed among women older than forty-three. Among women aged forty to forty-three, unintended pregnancy rate is about four per 100-women years with typical use. There are studies of other methods of NFP on small subsets of older women using NFP that show promising results, but they lack statistical power to draw firm conclusions regarding effectiveness.

The group concluded that more studies among perimenopause women using NFP are needed to understand better the perimenopause transition with the parameters of the menstrual cycle. There is a particular need to develop algorithms that can help women and health-care providers predict infertility and menopause. For example, a study by Taffe and Dennerstein (2002) indicates that when the differences of the length of the menstrual cycle goes beyond forty days, menopause will occur within eighteen months and women with this cycle length difference are infertile.

Technology and NFP

Apps for charting fertility cycles.

Menstrual cycle tracking apps are extremely popular; they are the fourth most common health app among adults and the second most popular among adolescent females ( Moglia et al. 2016 ). Today, these apps are used for help in avoiding pregnancy, achieving pregnancy, and simply tracking cycles. While popular, there is little objective evidence supporting the claims of most; most reviews and ratings refer to user characteristics rather than the underlying science supporting the predictions made by the app. The explosion in apps has significantly expanded the awareness of natural methods, but whether this translates into increased use of NFP broadly remains an open question today.

Duane et al. (2016) conducted a systematic review of ninety-five charting apps focused on the evidence-based method employed and accuracy in predicting the fertile window. Fifty-six (59 percent) of the identified apps had either no evidence-based support or were not designed to help avoid pregnancy. Ten apps did not interpret cycles, they only allow users to input data and make their own interpretation.

The remaining twenty-nine predicted the fertile window automatically using an algorithm. To test the accuracy of the algorithm to predict the fertile window, the beginning and end of the fertile window defined by the app was compared to the evidence-based fertile window in each of seven test cycles. Just six apps scored high on both authority (well-documented FABMs with evidence) and accuracy (complete agreement with the fertile window).

The Natural Cycles app, which employs basal body temperatures and a proprietary algorithm to define the fertile window, has recently obtained certification in the European Union as a medical device for contraception. While the certification is based primarily on meeting manufacturing quality standards, the developers have published an analysis of its initial users to define effectiveness when used to postpone pregnancy. Although the developers of this app system are to be applauded for conducting an effectiveness study, the study design includes several flaws including selection bias, lack of accurate pregnancy detection, and inappropriate analysis of perfect-use pregnancy rates ( Frank-Herrmann, Stanford, and Freundl 2017 ).

Recently Freis et al. (2018) proposed a scoring scheme to evaluate apps that claim to help users achieve pregnancy by predicting clinical ovulation. The scoring scheme seeks to identify those apps worthy of field-testing to validate their benefit in helping couples become pregnant. They also conducted a pilot test using twelve apps available in German and English that could be used without the need for additional devices (e.g., a urinary hormone test strip) using a set of completed cycles with known days of high fertility. Six of the apps were calendar-based and of little value to accurately predict the best days of fertility. The two apps employing temperature-only calculations did only marginally better at predicting clinical ovulation, while the remaining four apps which included a marker of estrogenic activity all scored well.

New Technologies for monitoring the fertile signs

Beyond apps, other technologies to define the daily fertility status are emerging. Several of these claimed “new technologies” are based on old ideas with little support. For example, new products based on saliva ferning patterns are available. Ferning has been shown to be an inaccurate surrogate for estimating the fertile phase of the menstrual cycle and to be highly sensitive to operator error. Further, saliva of men and menopausal women have been shown to have so-called fertile saliva, raising questions about its linkage to reproductive hormones.

Several devices marketed as an aide to conception (but not contraception) employ temperature-based algorithms to predict ovulation. Studies ( Ecochard et al. 2015 ) show that this approach is less precise than alternative at-home hormone tests or simply observing peak type cervical mucus. Similarly, electrical resistance measures, taken orally or vaginally, are inaccurate with many indeterminate results.

Electronic activity tracking bracelets and rings are widely available and popular. These wearable devices can passively monitor temperature, heart rate, skin conductivity, and other physiologic indicators. Whether or not these devices and the monitored physiologic parameters can make tracking fertility easier or more accurate is untested today. Continuous basal body temperatures (BBT) captured overnight while sleeping may be an alternative for waking BBT oral temperatures, but they need to be shown to be usable as an evidence-based NFP method or when integrated as a part of another NFP method.

Of the newer technologies, urinary hormone monitoring is emerging as a proven approach with several options available today or in development. Daily, at-home monitoring of urinary metabolites of estrogen, LH, and PdG is available today. Integration of urinary hormone detection with smartphones may provide for more consistent reading, and easier, more user-friendly interfaces are in development. A prototype mobile phone–based app that integrates measurement of FSH, LH, and PdG in an algorithm to define the fertile window was shown at the meeting. For infertile couples, daily, in-home, quantitative monitoring of five reproductive hormones via blood microsampling (as used in monitoring for diabetes) is under development and may be a reality in the future.

Based on the information presented and subsequent discussion, the group highlighted several key points regarding technology and NFP:

• Apps are unlikely to disappear and may well become the common method of daily charting.
• App popularity is raising awareness of NFP among the public, but with so many unconnected to an evidence-based method, there is a risk the public will be more misled than better informed regarding their fertility status.
• It would be useful to have some sort of objective evaluation of apps that potential users could turn to for a measure of the quality of the various apps.
• Effectiveness studies employing apps are needed for nearly all methods. Few if any well-designed prospective studies employing app-based charting are available today.
• New technologies, once they are established to be at least as accurate in predicting the fertile window as currently available observations, may improve and/or simplify the daily observation of fertility signs, expanding the appeal of NFP to a wider audience. However, studies on the impact of these new technologies on NFP are needed: do they improve persistence of use, or improve outcomes in special populations (e.g., postpartum women), or increase adoption and use of NFP?
• Integration of these technologies with mobile devices holds promise to reduce user uncertainty in interpretation and may lead to simpler, more user-friendly algorithms that allow persistent use of NFP.

Impact of NFP on Marital Dynamics

For this meeting, sixteen studies published between 1970 and 2017 that focused on the marital dynamics of NFP use were identified and reviewed. Although all had one or more limitations—including small sizes, low response rates, use of convenience samples, and frequent use of unique unvalidated measurement devices—several consistent themes emerged that support beneficial effects of NFP on marital dynamics.

Across all studies, users consistently perceive that using NFP has provided a better understanding of their fertility, increased intimacy, improved self-control/self-mastery, improved communication, and improved spiritual well-being. Importantly, users commonly acknowledge that the practice of NFP is difficult at times, but the struggle is seen by most as beneficial overall.

The claim that using NFP results in lower divorce has long been made by advocates of NFP, but those claims relied on anecdotal or methodologically questionable studies. Recent studies ( Fehring 2013 , 2015 ) using population-based samples indicate those who use NFP divorce at significantly lower rates compared to those who never used NFP. These more recent population-based studies support that lower divorce rates are associated with NFP use but also suggest that regular church attendance and importance of religion are at least as strongly associated with decreased divorce. Use of contraceptives, sterilization, and abortion are all associated with an increased risk of divorce; an observation worthy of further study to understand the societal cost of widespread use of contraceptives.

Several gaps in the evidence for the impact of NFP on marital relationships were identified, including the need for larger cohort studies sampled with less biases in both selection and response, more consistent use of validated survey instruments, and studies that include comparisons to other family planning methods. Long-term longitudinal studies are also needed as it is entirely possible that the perceived benefits and challenges of NFP shift over time.

Priorities for Future Work

At the meeting’s conclusion, the group generated a long list of potential research ideas and had a discussion to clarify each idea more fully. Afterward, the list was distributed to all who were invited to attend but could not. Each scientist was asked to prioritize the ideas and the results were collated. Five areas for future research in NFP were identified as high priority:

• important subpopulations (postpartum, perimenopause, posthormonal contraceptive);
• normally cycling women (especially US women); and
• comparative studies between NFP methods.
• Validation studies to establish the benefit of charting fertility signs (both currently known and potential new indicators) as a screening tool for women’s health issues (i.e., polycystic ovary syndrome, endometriosis, luteal phase insufficiencies, etc.).
• Ongoing independent evaluation of fertility monitoring apps to provide users with perspective on the relative merits of each and to identify those most worthy of further effectiveness testing.
• Studies evaluating the impact of new technologies on NFP adoption, use, and persistence. For example, smartphone reading of hormone test strips (i.e., FSH, LH, E3G, and PdG) to minimize interpretation confusion: do they impact persistence of use or improve outcomes in special populations (e.g., postpartum)?
• Creation of a shared database across various NFP methods to collaborate on shared research interests, longitudinal studies, and so on.

In addition, it was unanimously agreed that a future meeting in two to three years would be extremely valuable. Both established and younger researchers should attend to encourage and mentor those who will continue the work in the next generation. Such a meeting would be consistent with blessed Pope Paul VI’s (1968) directive to scientists in Humanae vitae (no. 24), who “can ‘considerably advance the welfare of marriage and the family, along with peace of conscience, if by pooling their efforts they labor to explain more thoroughly the various conditions favoring a proper regulation of births.’”

Acknowledgments

We wish to acknowledge those who attended this meeting as well as those unable to attend but who provided feedback during the voting on priorities.

Invited Scientists Attending

• Richard J. Fehring, PhD, RN, FAAN, Director and Professor emeritus, College of Nursing, Institute for Natural Family Planning (NFP), Marquette University
• Michael D. Manhart, PhD, Senior Scientific Consultant, Couple to Couple League International
• Joseph Stanford, MD, MPH, Professor of Medicine, University of Utah, Salt Lake City, UT
• Amy Beckley, PhD, Co-Founder Ovulation Double Check, CEO MBF Fertility Inc.
• Marguerite Duane, MD, Co-Founder, Fertility Appreciation Collaborative to Teach the Science
• William Williams, MD, Past Editor in Chief, Linacre Quarterly, Philadelphia, PA
• Qiyan Mu, PhD, RN, Veterans Administration and Medical College of Wisconsin Women’s Health Fellow
• Mary Schneider, MSN, FNP, PhD student, Assistant Director, Institute for NFP, Marquette University
• Theresa Hardy, RN, PhD, and NIH grantee, Postdoctoral Fellow, New York University
• Kathleen Raviele, MD, FACOG, Past President of Catholic Medical Association, Decatur, GA
• Bruno Scarpa, PhD, Professor of Biostatistics, University of Padua, Italy
• Petra Frank-Herrmann, MD, Women’s Health, University of Heidelberg, Germany
• Karen Poehailos, MD, member USCCB NFP advisory board

Invited Scientists Unable to Attend But Voting on Priorities

• Mary Lee Baron, PhD, FNP-BC, FAANP, Associate Professor, Southern Illinois University Edwardsville, School of Nursing
• Rene Leiva, MD, Assistant Professor with the Dept. Family Medicine, University of Ottawa, Canada
• Pilar Vigil, MD, PhD, FACOG, Pontifical Catholic University, Santiago, Chile
• Patrick Yeung Jr., MD, Associate Professor, Director SLUCare Restorative Fertility Clinic, Saint Louis University
• Paul Yong, MD, PhD, FRCSC, Research Director, BC Women’s Centre for Pelvic Pain & Endometriosis, and Assistant Professor in the University of British Colombia Division of Gynaecologic Specialties, Canada
• Rene Ecochard, MD, PhD, Professor Biostatics Unit, Department of Medical Information, Hospices Civils de Lyon, France
• Gunther Freundl, MD, Professor, Heinrich-Heine-Universität Düsseldorf , Germany
• Thomas Bouchard, MD, University of Calgary, Canada

Biographical Notes

Michael D. Manhart , PhD, is a senior scientific consultant to Couple to Couple League (CCL) International. He previously served as an executive director for CCL, and with his wife have been active Natural Family Planning teachers for over thirty years.

Richard J. Fehring , PhD, RN, FAAN, is a Professor Emeritus and director of College of Nursing, Institute, Natural Family Planning, Marquette University.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Natural family planning

Smoley, B. A., & Robinson, C. M. (2012). Natural family planning. American Family Physician, 86(10), 924–928.

Conclusion NFP methods are a viable and effective family planning option for motivated patients, and may be the ideal option for some. Interested couples require instruction in their chosen method.

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Natural family planning

Natural family planning is a way of preventing pregnancy.

The 2 main types of natural family planning involve:

• tracking periods to see when you’re most fertile and avoiding sex or using condoms on those days (fertility awareness method)
• breastfeeding your baby for up to 6 months to delay ovulation (lactational amenorrhoea method)

Withdrawing the penis before ejaculation (sometimes called the withdrawal method) is not an effective way to avoid pregnancy and is not recommended.

Natural family planning does not stop you getting or passing on sexually transmitted infections (STIs) . You need to use a condom to protect yourself and others against STIs, including HIV .

How well natural family planning works

Effectiveness of fertility awareness method.

When used correctly all the time, fertility awareness methods are between 91% and 99% effective at preventing pregnancy.

If you do not follow the instructions exactly, it is only 76% effective. This means 24 in 100 women will get pregnant when tracking their fertility for a year.

Effectiveness of lactational amenorrhea method

If you are breastfeeding and follow lactational amenorrhea method correctly all the time, it is more than 99% effective at preventing pregnancy.

If you do not follow the instructions exactly, it’s 98% effective and 2 in 100 women will get pregnant again within 6 months of giving birth.

Find out how effective other methods of contraception are at preventing pregnancy .

How to find out about natural family planning

You need an expert such as a fertility awareness practitioner or a midwife to teach you about natural family planning.

You can find out about natural family planning from:

• sexual health clinics, also called family planning or contraception clinics
• some GP surgeries
• some young people's services (call the national sexual health helpline on 0300 123 7123 for more information)

You can find a fertility awareness practitioner on the Fertility UK website .

If you’re pregnant, you can talk to your midwife about breastfeeding and the lactational amenorrhoea method.

How natural family planning works

There are different instructions for:

• tracking your menstrual cycle to know when you're fertile (fertility awareness method)
• breastfeeding a newborn baby to delay ovulation (lactational amenorrhoea method)

A healthcare professional specially trained in fertility awareness can teach you what you need to do every day for natural family planning to work.

Ask a midwife, or ask at a GP surgery or sexual health clinic to see if there’s someone available who can support you.

Using the fertility awareness method

With the fertility awareness method, you record the following every day:

• your body temperature
• details of your vaginal discharge
• your menstrual cycle

By tracking these you can see the days when you’re most likely to get pregnant (most fertile) each month. On fertile days, use a condom or avoid having sex.

It can take 2 to 3 menstrual cycles to understand how to do this properly. Use additional contraception during this time, or do not have sex.

There are apps and fertility monitoring devices designed to help you track your fertile days, but none are officially recommended by the NHS.

Using the lactational amenorrhoea method

With the lactional amenorrhoea method, you need to breastfeed your baby:

• at least every 4 hours during the day
• at least every 6 hours during the night

This method only works for the first 6 months after giving birth and you need to start as soon as you have your baby.

It will not work if you have a period, or you give your baby formula milk or solid food.

If you express breastmilk it may not be as effective, but there’s very little research into this.

Can I use natural family planning?

Natural family planning is not suitable for everyone.

It may be helpful if you cannot use other types of contraception because of a health condition.

Natural family planning may not be suitable for you if:

• you have irregular periods (fertility awareness method)
• you cannot breastfeed (lactational awareness method)
• you need to avoid getting pregnant due to a health condition
• you take a medicine that can affect your baby, such as some medicines for bipolar disorder, migraine and epilepsy

Speak to a doctor or nurse, or ask your midwife, if you want to know whether you can use natural family planning.

Do not stop taking your medicine without talking to a doctor first.

Further information

• Fertility UK: avoiding pregnancy – fertility awareness method
• Fertility UK: breastfeeding – lactational amenorrhoea method
• Fertility UK: find a fertility awareness practitioner in your area

Page last reviewed: 9 February 2024 Next review due: 9 February 2027

The DHS Program

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• Family Planning
• Maternal Mortality
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• Alcohol and Tobacco
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What is family planning?

Family planning refers to use of modern contraceptives or natural techniques to limit or space pregnancies. Modern methods of contraception include the pill, female and male sterilization, IUD, injectables, implants, male and female condom, diaphragm, and emergency contraception. Traditional methods include periodic abstinence, withdrawal and folk methods.

DHS data and family planning

The DHS collects data on knowledge and use of contraceptive methods, both modern and traditional. Women are also asked where they obtain their contraceptive method, and whether or not they were provided information during their contraceptive counseling that allowed them to make an informed choice. In order to assess missed opportunities, non-users of contraception are often asked if they have discussed family planning with health care providers. Men are also asked about their opinions towards family planning. In some surveys, information is also collected on exposure to family planning campaigns and coverage of social marketing programs. Extensive data on family planning are available on STATcompiler . Compare among countries and analyze trends over time.

Which DHS indicators are related to family planning?

• Knowledge of contraceptive methods (women and men)
• Ever use of contraception(women and men)
• Current use of contraception (women and men)
• Current use of contraception by background characteristics
• Number of children at first use
• Knowledge of fertile period (women and men)
• Contraceptive effect of breastfeeding
• Timing of sterilization
• Source of supply for modern contraceptive methods
• Contraceptive discontinuation rates
• Future use of contraception
• Reason for not using contraception
• Preferred method of contraception for future use
• Heard family planning on radio and television or in a newspaper or magazine
• Acceptability of media messages on family planning
• Contact of non-users with family planning providers
• Planning is being used
• Was family planning use mainly the woman's/the husband/partner's or a joint decision
• Informed choice of family planning methods
• Unmet need for family planning

Which SPA data are related to family planning?

The Service Provision Assessment (SPA) survey collects data on family planning from the health facility perspective. The SPA monitors availability of family planning methods, equipment, client educational materials, availability of trained providers and the setting needed to adequately distribute and counsel women about family planning.

Photo credit: © 2005 CCP, Courtesy of Photoshare. A couple who survived the tsunami in Aceh, Indonesia are soon to have a child. Antenatal care was provided for pregnant women at a camp for internally displaced persons in Long Raya, Aceh Besar, Indonesia.

Over 90 publications regarding family planning are available  

Extensive data on family planning are available on STATcompiler; compare among countries and analyze trends over time.

• 2013 International Conference on Family Planning
• Implementing Best Practices Initiative - Knowledge Gateway
• Elements of Family Planning Success toolkit
• International Planned Parenthood Federation (IPPF)
• UNFPA - family planning portal
• RESPOND Project
• Population Reference Bureau - Reproductive Health indicators
• Knowledge 4 Health - Reproductive Health Gateway
• Contraceptive Prevalence Rate - interactive map
• Repositioning Family Planning: Guidelines for Advocacy Action

What to Expect in the Psychological Evaluation for Family Planning

Intended parents of third-party reproduction..

Posted June 4, 2024 | Reviewed by Abigail Fagan

• A Parent's Role
• Find a family counsellor near me
• Family planning through egg donor or surrogacy is complex and stirs up a mixed range of emotions.
• The psychological evaluation contains several parts: an interview, family history, mental health history.
• Think of this time as a way to reflect on your strengths and challenges and better prepare for parenthood.

The anticipation of becoming a parent is a spectrum of emotions including excitement, hesitation, and even vulnerability. If you’ve arrived at family planning with the plan of third-party reproduction efforts, your journey has likely meant confusion, loss, cyclical hope and disappointment, and frustration. Your path has also meant reflective honesty, complicated communication, love, determination, and resilience .

The Psychological Evaluation: What Is It?

One of your many doctors’ appointments will include a psychological evaluation. It is an essential step to ensuring the best for your future family. The main goal of this meeting is to speak with a knowledgeable psychologist to think through your needs and wishes for the surrogate or egg donor, predict difficult parts of the journey and how to prepare emotionally for them, and to discuss and prepare for some of the early challenges of parenthood .

The psychological evaluation resembles a thorough health check-up for your mind and emotions. The psychologist will offer support as you discuss your strengths, uncover potential challenges, or risks, and identify areas requiring additional consideration.

The Interview

Interviews are like the first chapter of your story. The psychologist will ask you and your partner detailed questions about your background, family history, relationship dynamics, parenting experiences, and physical and emotional health. These questions aren’t a test of any sort, but, rather, it is a way for the professional to understand your emotional life and support you and your partner in welcoming a new baby.

Talking About the Hard Stuff

In the evaluation, we'll dig into your medical history, especially your mental health background. It's not about reopening old wounds, but about understanding how you and your partner have coped with challenges in the past.

The psychologist will ask questions to better understand your relationship and see how you communicate and work together. This includes how you talk to each other, share your feelings, and deal with challenges. The discussion may also include how you handle disagreements and support each other during difficult times.

Think of these discussions as helpful to pinpoint areas where both of you might benefit from extra support and ways to acknowledge and recognize your strengths as partners.

Lastly and importantly, you will talk about your plans to disclose your son or daughter’s unique birth narrative, which includes how they were conceived, and what that means for future contact and knowledge about their health. According to the American Society for Reproductive Medicine, openness is considered key, and parents should feel comfortable sharing their child’s birth narrative with them once they begin to ask questions, or when the parents feel the time is right.

The ethics and guidelines around donors and surrogacy are nuanced as they account for the donor or surrogate’s wishes for privacy while also considering what is important for the child’s health. For example, some legal agreements may allow for contact should one or the other party develop a health condition that may have implication for the other. This evaluation, along with consultations with your lawyer, may provide opportunities for you to think through both your wishes and limits to disclosure.

Feedback and Recommendations

Finally, as your time together wraps up, your provider may have some short-term and long-term recommendations to support the wellbeing of your family and future little one. Many providers will provide resource lists with journal articles, board books, and online support options.

Reflection and Opportunity

Embrace the evaluation as an opportunity for growth for you and your partner. You will be able to identify the strengths you and your partner have and figure out your areas of growth. Reflecting on the journey you and your partner are partaking in will help you feel more confident in you and your partner’s abilities to be intended parents. Through this guided psychological evaluation, you're not just fulfilling a requirement; you're actively shaping your readiness to embrace the joys and challenges of parenthood.

https://www.conceiveabilities.com/about/blog/do-intended-parents-undergo-psychological-screening

https://southwestsurro.com/blog/why-intended-parents-need-psych-eval

Amy Vigliotti, Ph.D. , is a child and adult psychologist and the founder of the NYC group therapy practice, SelfWorks.

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Offering extended use of the contraceptive implant via an implementation science framework: a qualitative study of clinicians’ perceived barriers and facilitators

• Nicole Rigler 1 ,
• Gennifer Kully 2 , 3 ,
• Marisa C. Hildebrand 2 ,
• Sarah Averbach 2 , 3 &
• Sheila K. Mody 2  

BMC Health Services Research volume  24 , Article number:  697 ( 2024 ) Cite this article

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Metrics details

The etonogestrel contraceptive implant is currently approved by the United States Food and Drug Administration (FDA) for the prevention of pregnancy up to 3 years. However, studies that suggest efficacy up to 5 years. There is little information on the prevalence of extended use and the factors that influence clinicians in offering extended use. We investigated clinician perspectives on the barriers and facilitators to offering extended use of the contraceptive implant.

Using the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured qualitative interviews. Participants were recruited from a nationwide survey study of reproductive health clinicians on their knowledge and perspective of extended use of the contraceptive implant. To optimize the diversity of perspectives, we purposefully sampled participants from this study. We used content analysis and consensual qualitative research methods to inform our coding and data analysis. Themes arose deductively and inductively.

We interviewed 20 clinicians including advance practice clinicians, family medicine physicians, obstetrician/gynecologist and complex family planning sub-specialists. Themes regarding barriers and facilitators to extended use of the contraceptive implant emerged. Barriers included the FDA approval for 3 years and clinician concern about liability in the context of off-label use of the contraceptive implant. Educational materials and a champion of extended use were facilitators.

Conclusions

There is opportunity to expand access to extended use of the contraceptive implant by developing educational materials for clinicians and patients, identifying a champion of extended use, and providing information on extended use prior to replacement appointments at 3 years.

Peer Review reports

The etonogestrel contraceptive implant is currently approved by the U.S. Food and Drug Administration (FDA) for 3 years of continuous use for the prevention of pregnancy [ 1 ]. However, there is evidence to support its use for up to 5 years while maintaining a low risk of pregnancy [ 2 , 3 , 4 ]. The off-label use of the contraceptive implant past its FDA-approved duration and up to 5 years is known as extended use. Importantly, the FDA supports off-label use of marketed drugs and medical devices so long as there is strong relevant published evidence [ 5 ]. Off-label use such as extended use of the contraceptive implant is common with many other reproductive devices and medications, including misoprostol for labor induction, the copper intrauterine device (IUD) for emergency contraception, and, prior to its recent FDA-approval for extended use, the 52 mg levonorgestrel (LNG) IUD for pregnancy prevention. The 52 mg LNG IUD was previously FDA-approved for 5 years, however strong published evidence demonstrated longer efficacy up to 8 years, leading clinicians to counsel on extended use and eventually contributing to updated federal guidelines [ 6 , 7 ].

Though there are clinicians who counsel patients on extended use of the contraceptive implant, many patients still undergo implant replacement after only 3 years of use [ 8 , 9 ]. Continuation rates of the contraceptive implant after 1 and 2 years of use is estimated to be at 81.7% and 68.7%, with the most common reason for early discontinuation prior to 3 years being changes to bleeding pattern [ 10 , 11 , 12 , 13 ]. Ali et al. report the most common reasons that patients decided to stop implant use in years 4 and 5: unspecified personal reasons, desired fertility, bleeding problems, and other medical reasons [ 4 ]. Additionally, a recent nationwide, web-based survey amongst a diverse group of reproductive health clinicians investigated the barriers and facilitators regarding extended use of the contraceptive implant up to 5 years [ 14 ]. The most common barriers found in the study were provider concerns about pregnancy risk and the current FDA approval for only 3 years of use. The key facilitators included strong published evidence supporting extended use and patient and clinician education on extended use. Other than these studies, the patient and clinician factors that facilitate and hinder widespread implementation of extended use of the contraceptive implant have not been explored.

Increasing implementation of extended use of the contraceptive implant across practice settings may decrease unnecessary procedures, devices, healthcare visits, and could improve access to, and satisfaction with, the contraceptive implant. Long-acting reversible contraceptive (LARC) methods such as the contraceptive implant and LNG IUD have significantly higher continuation and approval rates and are more efficacious at preventing pregnancy than non-LARC methods such as oral contraceptive pills and depot medroxyprogesterone acetate injection [ 12 , 15 , [ 16 ]. Given the continued high rates of unintended pregnancies in the United States and the consequential increase in healthcare costs and poor outcomes secondary to pregnancy complications, efficacious pregnancy prevention is an important public health objective and cost-saving measure [ 17 ].

Using a qualitative approach guided by an implementation science framework, the Consolidated Framework for Implementation Research (CFIR), [ 18 ] we sought to explore clinician perspectives on extended use of the contraceptive implant up to 5 years as well as the perceived barriers and facilitators for clinicians to offer extended use.

We conducted semi-structured interviews with 20 clinicians including obstetrics and gynecology generalists, family medicine physicians, complex family planning sub-specialists, and advanced practice clinicians. We recruited interview participants from a nationwide, web-based survey that assessed the prevalence of extended use of the contraceptive implant [ 17 ]. This study recruited respondents through email listservs for the Fellowship in Complex Family Planning, the Ryan Residency Training in Family Planning Program, women’s health nurse practitioners, and family medicine physicians, as well as private social media groups for obstetrician-gynecologists. The total reach of the survey was unknown, however, the study had a survey completion rate of 66.6% ( n  = 300/450). Of the 300 completed surveys, 290 respondents indicated their interest in being interviewed (96.7%).

Among the survey respondents, we invited 24 clinicians to participate in interviews, yielding an 83.3% response rate. We selectively recruited interview participants to enrich our sample, specifically focusing on clinician type, practice setting, and region of practice within the United States (U.S.). We also selected interview participants based on whether they always, sometimes, or never counsel on extended use to investigate a broad range of perspectives. For this study, offering extended use is defined as counseling on use past the current FDA-approved duration of 3 years and up to 5 years of use. Offering extended use can occur at any clinical encounter, including insertion appointments, replacement and removal appointments at or before 3 years, and general reproductive health appointments. Clinicians who always offer extended use were defined as those who counsel on extended use to patients who are considering or currently have the contraceptive implant. Clinicians who sometimes offer extended use were defined as those who counsel on extended use, but only to particular patients based on patient-specific factors such as body mass index or insurance coverage. Clinicians who never offer extended use were defined as those who never counsel on use of the contraceptive implant past 3 years of use.

The interview guide was created utilizing an implementation science framework that identifies factors for effectively enacting interventions [ 18 ]. The Consolidated Framework for Implementation Research (CFIR) is organized into 5 major domains: characteristics of the intervention, individual characteristics, inner setting, outer setting, and the process of implementation. The first domain, intervention characteristics, relates to the inherent qualities of the intervention, such as pharmacologic properties and side effects of the contraceptive implant when used up to 5 years. Individual characteristics relates to the roles and characteristics of individual patients and clinicians interacting with the intervention, such as educational background and type of insurance coverage. The inner setting domain assesses the internal setting in which an intervention will be implemented (i.e., clinic type, culture, and policies). The broader context in which an intervention will be implemented, including national policies and social norms is evaluated within the outer setting domain. Finally, the process of implementation domain explores the activities and strategies used to implement the intervention, such as educational materials or clinician and staff trainings on extended use.

We designed the interview guide around these specific domains with questions that aimed to identify targeted strategies to support successful implementation. The complete interview guide is in Appendix A . The interview guide was designed with input from clinicians who regularly prescribe contraception, including extended use of the contraceptive implant, as well as CFIR and implementation science experts. The Human Research Protection Program at our institution approved the study.

A single research team member conducted semi-structured interviews via secure video conference between July and August 2021. Interview participants provided informed consent. All participants were asked a full set of open-ended questions based on the interview guide, with focused follow-up questions to further investigate potential themes or to clarify points. All interviews were audio recorded, then transcribed. For data analysis, we used a content analysis approach to identify concepts and patterns within the dataset [ 19 ]. Themes arose deductively and inductively, with deductive themes identified from the CFIR domains and inductive themes arising from interview insights. Consensual qualitative research methods informed both our data analysis and coding process [ 20 ]. Three authors were involved in the thematic coding of the transcripts. Initially, 5 transcripts were independently coded then checked for inter-coder reliability. Any disagreements were discussed, and a consensus was achieved. The remaining transcripts were then coded by one of the three authors. Once all interviews were coded, major themes and representative quotes were identified. The research team utilized ATLAS.ti for analysis [ 21 ].

Between July and August 2021, we interviewed 20 clinicians from a variety of clinical settings, regions, and women’s health professions, achieving the intended diversity of perspectives (Table  1 ). Among participants, 7 (35.0%) always, 8 (40.0%) sometimes, 5 (25.0%) never offer extended use of the contraceptive implant (Table 2 ).

Characteristics of the intervention

We found that changes to bleeding pattern in or after the third year of use was a barrier to clinicians offering extended use of the contraceptive implant. The participants in this study noted that perceived increases in the irregularity or frequency of a patient’s bleeding makes extended use of the implant difficult for patients to accept. One clinician noticed that some patients correlate changes in their bleeding pattern with a perceived decrease in the efficacy of their implant:

"People who do start noticing changes in bleeding pattern […] [and] associating that with, ‘Oh, my implant is wearing out or becoming expired. I need to get this changed out."

-Complex Family Planning Specialist, Southwest, Academic Setting, sometimes offers extended use

The same clinician discussed that more research on bleeding patterns in the extended use period and potential treatments for implant-associated irregularities could be a facilitator of extended use:

"For bleeding, I think it would be awesome if there is a research study, looking at use of OCPs [oral contraceptive pills] to manage bleeding near the end of the use of an implant or near that three-year mark,, […] So that we could give people… Honestly, either a natural history or a, ‘Here’s how you can manage that if you do want to keep using your implant longer.’"

- Complex Family Planning Specialist, Southwest, Academic Setting, sometimes offers extended use

Information on the bleeding pattern in years 4 and 5 of use and how clinicians can address irregular bleeding during implant use may increase acceptability of extended use.

Individual characteristics

We found that insurance impacts whether a clinician offers extended use:

"I do sometimes have patients saying, ‘I might be changing jobs or I’m going to be turning 27 or whatever.’ And so insurance is a barrier and so they’re like, ‘I want the new one while I still have this insurance.’"

- Family Medicine Physician, Midwest, Community Setting, sometimes offers extended use

Many participants agreed with this concept and stated that acceptability of extended use depends on a patient’s perception of their future insurance status. Clinicians observed that if a patient believes they will have coverage for a replacement or removal in the future, they are more likely to pursue extended use of their implant. Conversely, one clinician discussed how lack of current insurance coverage could be a facilitator of extended use:

"So, I would generally offer extended use to people that didn’t have insurance and would have to self-pay. I would like go through the data with them so they wouldn’t have to pay like $1,000 to get a new implant because it could work another year, or people that were concerned about changing side effects at that time."

- Obstetrician-Gynecologist, Southwest, Academic Setting, sometimes offers extended use

Overall, clinicians perceived that patients’ concerns about current and future insurance coverage may affect acceptance of extended use.

Inner setting

This study found that having a champion of extended use at a clinician’s home or affiliate institution was a facilitator of extended use. Most clinicians in the study stated that it is or would be helpful to have someone who worked with them clinically that was knowledgeable on the data about extended use. When asked which factor would promote extended use of the implant the most, this clinician stated:

"…having a champion who is really ready to present the evidence, because the evidence can be there, but people don’t have time to read it. If it’s not brought to them, they’re not really going to know about it."

- Obstetrician-Gynecologist, West Coast, Community Setting, does not offer extended use

Potential champions identified were physicians, nurses, medical directors, or other clinicians in leadership positions, but participants generally believed that the position should be held by someone who is passionate about contraception, highly familiar with the specific setting, and knowledgeable about the clinical studies on extended use.

A barrier noted by a few participants was the effect of discordant counseling by different clinicians, sometimes within the same clinic, on acceptability of extended use:

"I mean, I guess like getting everyone on the same page, like in your practice can be a barrier. Especially in the practice I’ve been at, which like I said was in a state that was very litigious, so people weren’t always willing to like go outside guidelines that were… So getting your whole group on the same page so patients get like a more consistent message."

- Obstetrician-Gynecologist, Southwest, Academic Setting, sometimes offers extended use.

Participants discussed that it is important for clinician teams to relay a cohesive message to patients, especially in settings where patients may see multiple clinicians for their contraceptive care.

Outer setting

Lack of FDA approval for extended use was identified as barrier by many clinicians, and some clinicians counseled patients only on the FDA-approved duration of the contraceptive implant:

"So, generally in our practice we don’t really talk about extended use. We say this is FDA approved for three years."

- Advanced Practice Clinician, Southeast, Community Setting, sometimes offers extended use.

Even clinicians who do offer extended use of the implant noted that off-label use can be confusing to patients, making it difficult to counsel on extended use:

"So I have patients all the time, who’ll say, ‘Well, what do you mean I can keep X, Y or Z in for an extra year?’ And I’ll say, ‘We have big studies that tell us that this is an okay thing to do.’ But that just feels weird. People don’t necessarily understand the role of the FDA or sort of how it works. And so it’s something like extended use just might be a really such a foreign concept. Right? It’s so far outside. But I think that there are also, there are lay outlets that cover this stuff. So it’s not that it’s impossible to access. It’s just that the patient has to be interested just like the provider has to be interested."

- Complex Family Planning Specialist, East Coast, Academic Setting, sometimes offers extended use.

Clinicians also observed that certain clinics must follow official guidelines without the flexibility to offer extended use, regardless of a clinician’s perspective or willingness to counsel on extended use. Interestingly, patient confusion as well as mistrust of the healthcare system may impact patient acceptability of extended use in the context of a three-year FDA-approved duration:

"The other thing is the FDA approval because the box says three years, but then like I tell people, you can take it out in five years. And then they don’t believe… Like who is right. Is it my doctor who’s getting in front of me right or the box, right?"

- Family Medicine Physician, West Coast, Community Setting, always offers extended use.

This clinician noted that a disconnect between a clinician’s counseling and prescription information may lead patients to be confused about the recommendation for extended use.

Another barrier mentioned by a few participants was provider concern about liability in the event of an unintended pregnancy. Participants discussed fear of both legal and interpersonal repercussions of unintended pregnancy after counseling on off-label use of a contraceptive device:

"Even though there’s a slim chance that a patient would get pregnant on Nexplanon [the contraceptive implant], I feel like if we were to say, ‘Yeah, you can use it beyond the four years,’ and they come up and they get pregnant, they’re that 1% chance that gets pregnant, I feel like there could be a little bit of blame laid on us if we were to tell them that they’re able to it beyond the three years when the label doesn’t say that yet."

- Advanced Practice Clinician, Southeast, Private Practice, does not offer extended use.

Some participants felt that they would “have no ground to stand on” in the event of a lawsuit (OBGYN Physician, Midwest, Private Practice), making them concerned about the possibility of increased liability in counseling on off-label use without FDA approval.

Interestingly, multiple clinicians also discussed abortion restrictions in the United States as influencing patients in their decision to pursue extended use or not:

"In the past four years [2017–2021] have also had a lot of patients express concern about the administration. And so wanting to kind of be as current as they can be with their devices and so potentially exchanging them sooner than they need."

- Complex Family Planning Specialist, West Coast, Academic Setting, always offers extended use.

Clinicians observed that patients are noticing and reacting to abortion restrictions when making their contraceptive decisions, which may impact the widespread implementation of extended use.

Process of implementation

Many clinicians reported that a barrier to implementing extended use was patient preference for removal when they are already in clinic for a scheduled removal or replacement procedure, regardless of being counseled on extended use at that time:

“’Oh, I’m already here. I’m approved. Let’s just go ahead and get it done.’ So there’s probably not a whole lot you can do about that either, once they’re already in the clinic, and have their mind set on it.”

- Obstetrician-Gynecologist, Southeast, Academic Setting, does not offer extended use.

Many participants in this study noted that patients have made logistical arrangements prior to their appointments including paid time off, childcare, or prior authorization. It can be difficult for clinicians to offer extended use within this context, therefore counseling is better done prior to a patient coming in for a replacement appointment.

A perceived facilitator of extended use that was mentioned often was clear, concise clinician educational services or materials that illustrates existing data on efficacy and risks. Clinicians believed that this education could be in the form of continued medical education, targeted trainings, or written summaries of relevant studies, data, and recommendations. One consistency across interviews was that education on extended use must be integrated into regular practice and be easily understood by busy clinicians:

"I think that when we get a pamphlet or a brochure or a one page, something that just has everything condensed so it’s a really quick, oh, okay, this is something that we can be offering patients. And these are the reasons why it would be a benefit to them, and these are the patients that maybe would fall out of not offering this to. I think because of how busy we are, that’s the best way for us to make change."

- Advanced Practice Clinician, Southwest, Academic Setting, does not offer extended use.

Participants reported that these resources should be widely distributed beyond the complex family planning and obstetrician-gynecology community to increase accessibility to extended use.

Another potential facilitator identified was effective patient educational materials such as flyers that state the 5-year efficacy of the contraceptive implant, though producing these might require FDA approval. Participants in this study report that patients rely on clinicians to provide information on the efficacy and duration of their contraceptive implant. However, it is difficult for patients to accept extended use when there are inconsistencies across multiple sources of information:

"I mean, if online, there was information where it said you can keep it in for three to five years and they’re able to back that up. You know, people like to do their own research. I think that would be helpful, versus it says everywhere three, three, three, three, three, and then you’re the only person telling them something different, then it’s a little more tricky."

- Obstetrician-Gynecologist, West Coast, Community Setting, does not offer extended use.

Overall, participants in this study expressed that it would be helpful to have easily understood information for clinicians and patients that explained the evidence for extended use.

Our results demonstrate that there is an opportunity to increase widespread implementation of extended use through multiple interventions. Clinicians reported that patients prefer to have their implants replaced when they are already in clinic for the procedure. Therefore, intervening prior to replacement appointments at 3 years in the form of telemedicine visits or notifications from scheduling staff may make extended use of the contraceptive implant more acceptable to patients. Further, clinician and patient education on extended use that is easily understood and widely disseminated would likely increase use of the contraceptive implant up to 5 years.

The implementation of extended use of the contraceptive implant up to 5 years likely decreases healthcare costs secondary to fewer procedures and unintended pregnancies, and expands reproductive choices for patients seeking contraception. It has been found that clinicians who offer extended use state that most of their patients accept extended use when it is offered [ 14 ]. However, the reasons why a patient may or may not accept extended use are unclear, but may include changes in bleeding and concerns about use past the FDA-approved duration. Research on bleeding patterns in the extended use period may facilitate counseling and give patients a better expectation of possible changes they may see in years 4 and 5. Additionally, research on the patient perspective and acceptability of using the contraceptive implant past its FDA-approved timeframe is needed.

This study focused on clinicians and their perspectives on extended use. However, it is important to note that patients may be fully informed about extended use and choose to replace their implant at or before 3 years of duration. All discussions regarding contraception, including extended use of the implant, should always occur within a patient-centered and shared decision-making model. Widespread offering of extended use may allow for more patients to make fully informed decisions about the duration and use of their contraceptive devices, therefore expanding reproductive choice and agency in addition to potentially sparing patients from unnecessary procedures and extra healthcare costs.

Interestingly, although there are data to reflect high implant efficacy in years 4 and 5, [ 2 , 3 , 4 ] some participants in this study believe there is increased liability in counseling on off-label use without FDA approval. Importantly, off-label use is common among reproductive clinicians and is protected by the FDA if there is strong published evidence supporting off label use [ 5 ]. Additionally, the Society of Family Planning supports extended use of the contraceptive implant up to 5 years [ 22 ]. The FDA requires implant training for clinicians before they can insert or remove the implant. This training includes the FDA product labeling indicating the maximum duration of use for pregnancy prevention as three years [ 1 ]. It is possible that clinician training and product labels that advertise a 3-year duration dissuade clinicians from offering extended use of the contraceptive implant due to concerns about legal repercussions in the event of an unintended pregnancy with extended use. Therefore, organization- or systems-level guidelines, policy changes, and trainings in support of extended use may allow clinicians to feel comfortable offering off-label use of the implant. Additionally, FDA approval of the contraceptive implant to 5 years would likely greatly facilitate implementation of extended use.

Changing the FDA label to reflect extended use can be expensive, and contraceptive companies may not be incentivized to change the label. However, increasing the FDA approval of the contraceptive implant would allow for companies to have a longer-acting contraceptive device that is more directly comparable to other LARC devices such as the 52 mg LNG IUD that can be used for up to 8 years. If FDA approval for 5 years of use were to occur, it is not known if the barriers described in this study would continue to apply. However, it is likely that the facilitators of extended use from this study would support implementation of extended use irrespective of the federally approved duration.

One strength of the study is the national sample and the diversity of clinician types and settings. There is also representation of clinicians who consistently offer extended use and those who do not offer extended use. Another strength of this study is that it was designed utilizing a framework focusing on implementation, thus yielding results that can be used to create effective interventions.

Limitations of this study include the small sample size and selection bias from recruiting from a prior study that utilized listservs and social media. Additionally, we recruited from a population that was specifically interested in family planning and identified mostly as Caucasian and female. Because of this, our results may not be generalizable to the national population of clinicians who offer contraceptive implant services. However, our direct selection of participants who only sometimes or do not offer extended use allowed us to hear diverse perspectives regardless of prior knowledge or interest in extended use. Another limitation is that we did not ask advanced practice clinicians what their specific training was (i.e., nurse practitioner or physician’s assistant). As the training for advanced practice clinicians can vary greatly, our results may not be generalizable to all advanced practice clinicians.

In conclusion, this study describes the barriers and facilitators to widespread implementation of extended use of the contraceptive implant. These results offer new perspectives and potential strategies to increase widespread implementation of extended use of the contraceptive implant up to 5 years of use. Based on our findings, there is opportunity to expand access to extended use by developing educational materials for clinicians and patients, identifying a champion of extended use, and counseling on extended use prior to removal appointments at 3 years. Of note, these results should be viewed in the context of recent policy access issues regarding reproductive health and used to support patient-centered contraceptive choices, regardless of a patient’s decision to extend use of their contraceptive implant up to 5 years. It is important that clinicians and patients utilize shared decision making when discussing extended use of the contraceptive implant.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to being stored in a private, HIPAA-compliant database, but are available from the corresponding author on reasonable request.

Abbreviations

Consolidated Framework for Implementation Research

Food and Drug Administration

CoIntrauterine device

• Long-acting reversible contraception

Levonorgestrel

Obstetrician-Gynecologist

United States

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Acknowledgements

We thank the participants in this study.

This study was funded by Organon (Study #201908). The funder had no role in the study design, analysis, or interpretation of findings.

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School of Medicine, University of California San Diego, San Diego, CA, USA

Nicole Rigler

Division of Complex Family Planning, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, 9300 Campus Point Dr. MC 7433, La Jolla, San Diego, CA, USA

Gennifer Kully, Marisa C. Hildebrand, Sarah Averbach & Sheila K. Mody

Center on Gender Equity and Health, University of California, San Diego, CA, USA

Gennifer Kully & Sarah Averbach

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Contributions

SM is the principal investigator and lead data analysis, including qualitative coding, and dissemination of findings. She was also involved in study design and participant recruitment. NR was the primary interviewer and was involved in study design, recruitment, data management, data analysis, and dissemination of findings. GK and MH were involved with study design, recruitment, coordination of the study, IRB documentation, data analysis, and dissemination of findings. SA was involved with study design and dissemination of findings. All authors read and approved the final draft of the manuscript.

Corresponding author

Correspondence to Sheila K. Mody .

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Rigler, N., Kully, G., Hildebrand, M.C. et al. Offering extended use of the contraceptive implant via an implementation science framework: a qualitative study of clinicians’ perceived barriers and facilitators. BMC Health Serv Res 24 , 697 (2024). https://doi.org/10.1186/s12913-024-10991-4

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Q&A: These researchers examined 20 years of data on same-sex marriage. Here’s what they found

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Twenty years ago this month, Marcia Kadish and Tanya McCloskey exchanged wedding vows at Cambridge City Hall in Massachusetts and became the first same-sex couple to legally marry in the United States .

The couple had been together since 1986, but their decision to wed was radical for its time. In 2004, only 31% of Americans supported same-sex marriage, while 60% were opposed , according to a Pew Research Center poll.

Much of that opposition was fueled by fears that expanding the definition of marriage beyond the traditional union of a man and a women would undermine the institution and be destabilizing to families. Researchers at the Rand Corp. decided to find out if those predictions turned out to be true.

A team from the Santa Monica-based think tank spent a year poring over the data. The result is a 186-page report that should be reassuring to supporters of marriage equality.

“If there were negative consequences in the last 20 years of the decision to legalize marriage for same-sex couples, no one has yet been able to measure them,” said Benjamin Karney , an adjunct behavioral scientist at Rand.

Karney, who is also a social psychologist at UCLA, led the report with Melanie Zaber , a labor economist and economic demographer at Rand. They spoke with The Times about what they learned.

Does marriage make people better off?

Benjamin Karney: On average, yes. People who are married experience fewer health problems , they live years longer , they make more money , and they accumulate more wealth than people who marry and divorce or who don’t marry at all. People who are married also experience more stable and positive psychological health , and they have sex more frequently than people who are not married.

All those benefits accrue primarily to people who are in happy marriages. Unhappy marriage is very, very harmful. But most people who are married are happy — that’s why they stay married.

What prompted you to examine same-sex marriage now?

BK: At the time that these policies were changing, there were a lot of arguments on both sides about whether the consequences would be positive or negative. Twenty years is a long time, and during that time, a lot of research has been conducted. It seemed like a good time to ask the question: What did happen as a consequence of legalizing marriage for same-sex couples? So that’s one reason.

The second reason is that in the Dobbs decision that overturned Roe vs. Wade , Justice Clarence Thomas in his concurring opinion said explicitly that this Supreme Court should consider reviewing and potentially overturning other decisions , and he named the 2015 Obergefell vs. Hodges decision that legalized marriage for same-sex couples by name. Given that people may be wondering about the merits of that decision, it seemed like a good time to evaluate the consequences of that decision, and that’s what we’ve done.

What did you find?

BK: We found 96 studies across a range of disciplines. Some are in economics. Some are in psychology. Some are in medicine. Some are in public health.

Melanie Zaber: We wanted it to be research that actually measured something. There were a number of more qualitative or theoretical or legal arguments that we excluded.

BK: What I found most notable is that all of the studies drew the same conclusions: There was either no effect or beneficial effects on any outcome you could look at. That’s 20 years of research, 96 studies, and no harms.

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Does it seem plausible that the results could be so one-sided?

BK: I was not surprised. There’s a lot of good theory in family science and relationship science to argue that if you extend rights to a group that’s been stigmatized, that group should do better, and the majority group should not be affected. Indeed, that’s what we found.

MZ: I don’t find it particularly surprising. When we say there are no harms, that doesn’t mean everything’s coming up sunshine and roses — it means sunshine and roses or nothing. In this case, where the prediction was something negative, then nothing still feels like sunshine and roses.

What sorts of things did these studies measure?

BK: There were three general categories. The largest group was looking at outcomes for LGBT individuals and same-sex couples. The second bucket looked at the children of same-sex parents. And the third bucket was the effect on everybody else.

There was no evidence of harms anywhere.

That’s interesting because opponents of these policy changes very strongly — and very explicitly — predicted there would be harms. They predicted it in front of the Supreme Court , arguing that if we allow same-sex couples to marry, the consequences for the country will be negative and severe and unavoidable and irreversible.

Who benefits the most from legalizing same-sex marriage?

BK: Same-sex couples. Their relationships last longer when they are able to marry and cement their commitment. Their incomes go up. Their mental health improves.

That mental health improvement extends to LGBT individuals whether or not they are married. Even if you’re not married , if you’re a member of a sexual minority and live in a world that validates same-sex relationships, that relieves a stressor and has measurable benefits on physical and mental health.

What’s behind these improvements?

BK: The effects on health seem like they operate partly through employer-based health insurance being extended to spouses.

The mechanisms for mental health have been described by minority stress theory . Living in a society that is constantly sending you a message that you are less worthy of equal treatment is stressful, partly because it leads to discrimination. Being the target of discrimination is stressful , and that stress has real mental and physical consequences .

You found 96 studies about gay marriage. Why did you conduct your own research as well?

MZ: Some of those studies were conducted when only a few states had marriage for same-sex couples. A state like West Virginia or Wyoming might say, “Well that’s all well and good that you have evidence from Massachusetts or Vermont, but New England isn’t the center of the universe.”

By looking at a broader range of years, we’re better able to capture some of those states that did allow same-sex couples to marry but weren’t among the first to do so. We have reason to think those states may be very different environments. Our approach was to use each state as a quasi-experiment.

What did all that data tell you?

MZ: The headline from our new analysis is no negative impacts and some positive ones.

We see an increase in marriage, and that increase is driven not just by newly marrying same-sex couples, but also by an increase in marriage among different-sex couples. That was a bit surprising to us.

World & Nation

Hearing threat to Roe vs. Wade, I thought of my gay marriage — and Jim Obergefell’s fight

Like LGBTQ people nationwide, I can’t help but worry that the legal logic that might topple Roe will be used against my marriage.

May 16, 2022

What do you think was going on?

MZ: There are a few different mechanisms for this, none of which we can explicitly test.

One could be allyship . There are individuals who identify as cisgender straight individuals, but they want to show their allyship so they delay marriage until everyone’s able to marry.

There’s an increasing number of individuals who identify as bisexual in the United States. Even if they’re marrying a different-sex partner, they may be trying to have validation of their broader identity.

The argument we find most compelling is that having people loudly clamoring for all the great things that come along with marriage made people in the broader population say, “Oh hey, getting married means people can go visit me in the hospital, and that if I’m in an accident there’s no concern about who my property will go to, and we have more access to health insurance.” Talking about that may have made some people realize, “You know, marriage actually is pretty helpful.”

BK: If you hear about a restaurant that everyone’s trying to get into, you want to eat at that restaurant.

MZ: That is an excellent way of putting it!

Do you think this research will persuade those who were concerned that same-sex marriage would have terrible consequences?

MZ: That’s our goal — to put evidence out to the public so policymakers can make informed choices.

BK: I’d like to believe so. At the time those arguments were made, they were speculative. People were trying to predict the future. Now we don’t have to predict the future. Twenty years have passed and we have the data. We can document what has happened.

This interview has been edited for length and clarity.

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Greece just legalized same-sex marriage. Will other Orthodox Christian countries join them any time soon?

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Karen Kaplan covers science and medical research for the Los Angeles Times. She has been a member of the science team since 2005, including 13 years as an editor. Her first decade at The Times was spent covering technology in the Business section as both a reporter and editor. She grew up in San Diego and is a graduate of MIT and Columbia University.

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