Effectiveness of fertility awareness-based methods for pregnancy prevention during the postpartum period



      To summarize the evidence on typical and perfect-use effectiveness of fertility awareness-based methods for avoiding pregnancy during the postpartum period, whether breastfeeding or not.

      Study design

      We conducted a systematic review of studies published in English, Spanish, French, or German by November 2021 in MEDLINE, EMBASE, CINAHL, Web of Science, and Abstract and full text reviews were completed by 2 independent reviewers. Study inclusion: at least 50 subjects who enrolled prior to experiencing 3 cycles after childbirth and were using a specific fertility awareness-based method to avoid pregnancy; unintended pregnancy rate or probability calculated; postpartum amenorrheic and postpartum cycling individuals analyzed separately; and prospectively measured pregnancy intentions and outcomes. Outcomes were abstracted and study quality was systematically assessed by 2 independent investigators.


      Four studies provided effectiveness data for 1 specific fertility awareness-based method among postpartum individuals. Of these, there were zero high quality, 1 moderate quality, and 3 low quality for our question of interest. Typical-use pregnancy probability for the first 6 cycles postpartum for Marquette Method users was 12.0 per 100 women years (standard error [SE] not reported) and for Billings Ovulation Method users ranged from 9.1 (SE 3.9) for non-lactating women <30 years old to 26.8 (SE 4.6) for lactating women <30 years old. Typical-use pregnancy probabilities for the first 6 months post-first menses for the Postpartum Bridge to Standard Days Method users was 11.8 (95% confidence interval 6.01-17.16) and for Billings Ovulation Method users was 8.5 per 100 women (SE 1.7).


      The current evidence on the effectiveness of each fertility awareness-based method for postpartum persons is very limited and of mostly low quality. More high quality studies on the effectiveness of fertility awareness-based method in postpartum persons are needed to inform clinical counseling and patient-centered decision-making.


      Although postpartum individuals may desire to use fertility awareness-based methods to avoid pregnancy, the evidence of the effectiveness of fertility awareness-based methods in this population is limited. More high-quality studies are needed to inform shared decision-making.


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        • Dunson DB
        • Baird DD
        • Wilcox AJ
        • Weinberg CR.
        Day-specific probabilities of clinical pregnancy based on two studies with imperfect measures of ovulation.
        Hum Reprod. 1999; 14: 1835-1839
        • Lynch CD
        • Jackson LW
        • Buck Louis GM
        Estimation of the day-specific probabilities of conception: Current state of the knowledge and the relevance for epidemiological research.
        Paediatr Perinat Epidemiol. 2006; 20 (Suppl): 3-12
        • 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: 1517-1521
        • Polis CB
        • Jones RK.
        Multiple contraceptive method use and prevalence of fertility awareness based method use in the United States, 2013-2015.
        Contraception. 2018; 98: 188-192
        • Tepper NK
        • Curtis KM
        • Cox S
        • Whiteman MK.
        Update to U.S. medical eligibility criteria for contraceptive use, 2016: Updated recommendations for the use of contraception among women at high risk for HIV infection.
        MMWR Morb Mortal Wkly Rep. 2020; 69: 405-410
        • Berens P
        • Labbok M
        Academy of breastfeeding medicine. ABM clinical protocol #13: Contraception during breastfeeding, revised 2015.
        Breastfeed Med. 2015; 10: 3-12
        • Sachs HC
        Committee on drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics.
        Pediatrics. 2013; 132: e796-e809
        • Hatcher RA.
        • et al.
        Contraception after pregnancy.
        in: Kowal D Hatcher RA Nelson AL Trussell J Cwiak C Cason P Contraceptive Technology 21st Edition. 21st ed. Managing Contraception, 2018
        • Sinai I
        • Cachan J.
        A bridge for postpartum women to standard days method®: I. Developing the Bridge.
        Contraception. 2012; 86: 12-15
        • Van der Wijden C
        • Manion C.
        Lactational amenorrhoea method for family planning.
        Cochrane Database Syst Rev. 2015; CD001329
        • Kennedy KI
        • Visness CM.
        Contraceptive efficacy of lactational amenorrhoea.
        Lancet. 1992; 339: 227-230
        • Short RV
        • Lewis PR
        • Renfree MB
        • Shaw G.
        Contraceptive effects of extended lactational amenorrhoea: Beyond the Bellagio consensus.
        Lancet. 1991; 337: 715-717
        • Valdés V
        • Labbok MH
        • Pugin E
        • Perez A.
        The efficacy of the lactational amenorrhea method (LAM) among working women.
        Contraception. 2000; 62: 217-219
      1. Breastfeeding Report Card | Breastfeeding | CDC n.d. (accessed April 2, 2022).

        • Peragallo Urrutia R
        • Polis CB
        • Jensen ET
        • Greene ME
        • Kennedy E
        • Stanford JB
        Effectiveness of fertility awareness-based methods for pregnancy prevention: A systematic review.
        Obstet Gynecol. 2018; 132: 591-604
        • Gray RH
        • Campbell OM
        • Zacur HA
        • Labbok MH
        • MacRae SL.
        Postpartum return of ovarian activity in nonbreastfeeding women monitored by urinary assays.
        J Clin Endocrinol Metab. 1987; 64: 645-650
        • Harris RP
        • Helfand M
        • Woolf SH
        • Lohr KN
        • Mulrow CD
        • Teutsch SM
        • et al.
        Current methods of the US preventive services task force: A review of the process.
        Am J Prev Med. 2001; 20: 21-35
        • Trussell J
        • Grummer-Strawn L.
        Contraceptive failure of the ovulation method of periodic abstinence.
        Fam Plann Perspect. 1990; 22: 65-75
        • Weissmann MC
        • Foliaki L
        • Billings EL
        • Billings JJ.
        A trial of the ovulation method of family planning in Tonga.
        Lancet. 1972; 2: 813-816
        • Xu JX
        • Yan JH
        • Fan DZ
        • Zhang DW
        Billings natural family planning in Shanghai, China.
        Adv Contracept. 1994; 10: 195-204
        • Hilgers TW
        • Stanford JB.
        Creighton model naproeducation technology for avoiding pregnancy. Use effectiveness.
        J Reprod Med. 1998; 43: 495-502
        • Guerrero R
        • Lores H.
        [Evaluation of periodic continence as a method of family planning].
        Rev Colomb Obstet Ginecol. 1970; 21: 545-552
        • Doud J.
        Use effectiveness of the Creighton model of NFP.
        Int Rev Nat Fam Plann. 1985; 9: 54-72
        • 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: 222-230
        • Fehring RJ
        • Lawrence D
        • Philpot C.
        Use effectiveness of the Creighton model ovulation method of natural family planning.
        J Obstet Gynecol Neonatal Nurs. 1994; 23: 303-309
        • Pearson JT
        • Chelstowska M
        • Rowland SP
        • Mcilwaine E
        • Benhar E
        • Berglund Scherwitzl E
        • et al.
        Natural cycles app: Contraceptive outcomes and demographic analysis of UK users.
        Eur J Contracept Reprod Health Care. 2021; 26: 105-110
        • Ecochard R
        • Pinguet F
        • Ecochard I
        • De Gouvello R
        • Guy M
        • Huy F.
        [Analysis of natural family planning failures. In 7007 cycles of use].
        Contracept Fertil Sex. 1998; 26: 291-296
        • Fehring RJ
        • Schneider M
        • Raviele K.
        Pilot evaluation of an internet-based natural family planning education and service program.
        J Obstet Gynecol Neonatal Nurs. 2011; 40: 281-291
        • Fehring RJ
        • Schneider M.
        Effectiveness of a natural family planning service program.
        MCN Am J Matern Child Nurs. 2017; 42: 43-49
        • Dorairaj K.
        Use-effectiveness of fertility awareness among the urban poor.
        Soc Action (New York). 1984; 34: 286-306
        • Howard MP
        • Stanford JB.
        Pregnancy probabilities during use of the Creighton model fertility care system.
        Arch Fam Med. 1999; 8: 391-402
        • Mu Q
        • Fehring RJ
        • Bouchard T.
        Multisite effectiveness study of the marquette method of natural family planning program.
        Linacre Q. 2022; 89: 64-72
        • Sinai I
        • Cachan J.
        A bridge for postpartum women to standard days method®: II. Efficacy study.
        Contraception. 2012; 86: 16-21
        • Perez A
        • Labbok M
        • Barker D
        • Gray R.
        Use-effectiveness of the ovulation method initiated during postpartum breastfeeding.
        Contraception. 1988; 38: 499-508
        • Labbok MH
        • Stallings RY
        • Shah F
        • Pérez A
        • Klaus H
        • Jacobson M
        • et al.
        Ovulation method use during breastfeeding: Is there increased risk of unplanned pregnancy?.
        Am J Obstet Gynecol. 1991; 165: 2031-2036
        • Bouchard T
        • Fehring RJ
        • Schneider M.
        Efficacy of a new postpartum transition protocol for avoiding pregnancy.
        J Am Board Fam Med. 2013; 26: 35-44
        • Chao S.
        The effect of lactation on ovulation and fertility.
        Clin Perinatol. 1987; 14: 39-50
        • Tully KP
        • Stuebe AM
        • Verbiest SB.
        The fourth trimester: A critical transition period with unmet maternal health needs.
        Am J Obstet Gynecol. 2017; 217: 37-41
        • Zinaman M
        • Stevenson W.
        Efficacy of the symptothermal method of natural family planning in lactating women after the return of menses.
        Am J Obstet Gynecol. 1991; 165: 2037-2039
        • Moreau C
        • Cleland K
        • Trussell J.
        Contraceptive discontinuation attributed to method dissatisfaction in the United States.
        Contraception. 2007; 76: 267-272
        • Steiner M
        • Dominik R
        • Trussell J
        Hertz-Picciott I. Measuring contraceptive effectiveness: A conceptual framework.
        Obstet Gynecol. 1996; 88: 24S-30S
        • van der Graaf R
        • van der Zande ISE
        • den Ruijter HM
        • Oudijk MA
        • van Delden JJM
        • Oude Rengerink K
        • et al.
        Fair inclusion of pregnant women in clinical trials: An integrated scientific and ethical approach.
        Trials. 2018; 19: 78