A Mixed-Methods Assessment of Health Care Providers' Knowledge, Attitudes, and Practices Around Fertility Awareness-Based Methods in Title X Clinics in the United States

Abstract

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

Understanding the perspective of women who use the Billings Ovulation Method®: a focus group study

“…Despite the scientific evidence demonstrating that the Billings Method can be used to avoid pregnancy, there is still a lack of information and many misconceptions about Billings and other FABMs within the lay and medical communities [ 7 , 15 ]. The Billings Method is used by a small proportion of reproductive-aged women in the United States; however, two analyses of the National Survey of Family Growth showed the use of FABMs, in general, increased from 1.1% to 2.2% between 2008 and 2014 [ 16 ] and from 2.9 to 3.4% between 2013–2017 [ 17 ].…”

Physician Dispositions Toward Noninvasive Non-Hormonal Contraception

“…26 , 69 , 70 Patients who use or are interested in using FABMs for family planning may be especially vulnerable to physician interactions that do not meet these high expectations for contraceptive equity due to physician knowledge gaps surrounding FABMs demonstrated in this and other studies. 4 – 7 , 17 , 19 , 51 …”

“…26,69,70 Patients who use or are interested in using FABMs for family planning may be especially vulnerable to physician interactions that do not meet these high expectations for contraceptive equity due to physician knowledge gaps surrounding FABMs demonstrated in this and other studies. [4][5][6][7]17,19,51 Limitations. As a survey of willing participants at a single institution, these data are subject to selection bias and results may not be broadly generalizable.…”

“…14 , 15 Multiple studies have identified a need for improved coverage of FABMs in medical education. 1 , 4 , 5 , 7 , 15 – 17 According to the Guttmacher Institute, “relative to other methods of pregnancy prevention, substantial misinformation exists around fertility awareness based methods of contraception, particularly about the effectiveness of specific methods and how to use them.” 18 , 19 This is likely multifactorial and due to (1) varying FABM efficacy rates, which are often reported in aggregate, (2) incomplete knowledge of how efficacy compares to combined hormonal contraception, (3) conflation of all FABMs with the low efficacy “rhythm method,” (4) the additional time FABMs require in patient counseling, (5) no centralized databases of certified FABM instructors until 2021, and (6) physician concerns about patient adherence. 12 , 17 , 20 – 22 …”

“…18,19 This is likely multifactorial and due to (1) varying FABM efficacy rates, which are often reported in aggregate, (2) incomplete knowledge of how efficacy compares to combined hormonal contraception, (3) conflation of all FABMs with the low efficacy "rhythm method," (4) the additional time FABMs require in patient counseling, (5) no centralized databases of certified FABM instructors until 2021, and ( 6) physician concerns about patient adherence. 12,17,[20][21][22] Reasons for patient interest in FABMs include contraindications to hormonal contraceptives, 23,24 preference to avoid exogenous hormones, 25 preference to avoid contraceptive devices/implants, [26][27][28] concern for preventing embryo implantation, 29,30 desire for improved body literacy, 31,32 or in appropriate cases, achieving pregnancy without the use of assisted reproductive technology due to patient preference and/or financial constraints. [33][34][35][36] Information available to the public about family planning options, including FABMs, varies in quality and accuracy.…”