Abstract
Objectives
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 ClinicalTrials.gov.
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.
Results
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).
Conclusion
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.
Implications
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.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to ContraceptionAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Day-specific probabilities of clinical pregnancy based on two studies with imperfect measures of ovulation.Hum Reprod. 1999; 14: 1835-1839https://doi.org/10.1093/humrep/14.7.1835
- 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): 3-12https://doi.org/10.1111/j.1365-3016.2006.00765.x
- 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: 1517-1521https://doi.org/10.1056/NEJM199512073332301
- Multiple contraceptive method use and prevalence of fertility awareness based method use in the United States, 2013-2015.Contraception. 2018; 98: 188-192https://doi.org/10.1016/j.contraception.2018.04.013
- 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: 405-410https://doi.org/10.15585/mmwr.mm6914a3
- Academy of breastfeeding medicine. ABM clinical protocol #13: Contraception during breastfeeding, revised 2015.Breastfeed Med. 2015; 10: 3-12https://doi.org/10.1089/bfm.2015.9999
- Committee on drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics.Pediatrics. 2013; 132: e796-e809https://doi.org/10.1542/peds.2013-1985
- 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
- A bridge for postpartum women to standard days method®: I. Developing the Bridge.Contraception. 2012; 86: 12-15https://doi.org/10.1016/j.contraception.2011.11.009
- Lactational amenorrhoea method for family planning.Cochrane Database Syst Rev. 2015; CD001329https://doi.org/10.1002/14651858.CD001329.pub2
- Contraceptive efficacy of lactational amenorrhoea.Lancet. 1992; 339: 227-230https://doi.org/10.1016/0140-6736(92)90018-x
- Contraceptive effects of extended lactational amenorrhoea: Beyond the Bellagio consensus.Lancet. 1991; 337: 715-717https://doi.org/10.1016/0140-6736(91)90288-z
- The efficacy of the lactational amenorrhea method (LAM) among working women.Contraception. 2000; 62: 217-219https://doi.org/10.1016/s0010-7824(00)00170-0
Breastfeeding Report Card | Breastfeeding | CDC n.d. https://www.cdc.gov/breastfeeding/data/reportcard.html (accessed April 2, 2022).
- Effectiveness of fertility awareness-based methods for pregnancy prevention: A systematic review.Obstet Gynecol. 2018; 132: 591-604https://doi.org/10.1097/AOG.0000000000002784
- Postpartum return of ovarian activity in nonbreastfeeding women monitored by urinary assays.J Clin Endocrinol Metab. 1987; 64: 645-650https://doi.org/10.1210/jcem-64-4-645
- Current methods of the US preventive services task force: A review of the process.Am J Prev Med. 2001; 20: 21-35https://doi.org/10.1016/s0749-3797(01)00261-6
- Contraceptive failure of the ovulation method of periodic abstinence.Fam Plann Perspect. 1990; 22: 65-75
- A trial of the ovulation method of family planning in Tonga.Lancet. 1972; 2: 813-816
- Billings natural family planning in Shanghai, China.Adv Contracept. 1994; 10: 195-204https://doi.org/10.1007/BF01983351
- Creighton model naproeducation technology for avoiding pregnancy. Use effectiveness.J Reprod Med. 1998; 43: 495-502
- [Evaluation of periodic continence as a method of family planning].Rev Colomb Obstet Ginecol. 1970; 21: 545-552
- Use effectiveness of the Creighton model of NFP.Int Rev Nat Fam Plann. 1985; 9: 54-72
- Effectiveness of the sympto-thermal method of natural family planning: An international study.Int J Fertil. 1981; 26: 222-230
- Use effectiveness of the Creighton model ovulation method of natural family planning.J Obstet Gynecol Neonatal Nurs. 1994; 23: 303-309
- Natural cycles app: Contraceptive outcomes and demographic analysis of UK users.Eur J Contracept Reprod Health Care. 2021; 26: 105-110https://doi.org/10.1080/13625187.2020.1867844
- [Analysis of natural family planning failures. In 7007 cycles of use].Contracept Fertil Sex. 1998; 26: 291-296
- Pilot evaluation of an internet-based natural family planning education and service program.J Obstet Gynecol Neonatal Nurs. 2011; 40: 281-291https://doi.org/10.1111/j.1552-6909.2011.01237.x
- Effectiveness of a natural family planning service program.MCN Am J Matern Child Nurs. 2017; 42: 43-49https://doi.org/10.1097/NMC.0000000000000296
- Use-effectiveness of fertility awareness among the urban poor.Soc Action (New York). 1984; 34: 286-306
- Pregnancy probabilities during use of the Creighton model fertility care system.Arch Fam Med. 1999; 8: 391-402
- Multisite effectiveness study of the marquette method of natural family planning program.Linacre Q. 2022; 89: 64-72https://doi.org/10.1177/0024363920957515
- A bridge for postpartum women to standard days method®: II. Efficacy study.Contraception. 2012; 86: 16-21https://doi.org/10.1016/j.contraception.2011.11.008
- Use-effectiveness of the ovulation method initiated during postpartum breastfeeding.Contraception. 1988; 38: 499-508https://doi.org/10.1016/0010-7824(88)90154-0
- Ovulation method use during breastfeeding: Is there increased risk of unplanned pregnancy?.Am J Obstet Gynecol. 1991; 165: 2031-2036https://doi.org/10.1016/s0002-9378(11)90574-2
- Efficacy of a new postpartum transition protocol for avoiding pregnancy.J Am Board Fam Med. 2013; 26: 35-44https://doi.org/10.3122/jabfm.2013.01.120126
- The effect of lactation on ovulation and fertility.Clin Perinatol. 1987; 14: 39-50
- The fourth trimester: A critical transition period with unmet maternal health needs.Am J Obstet Gynecol. 2017; 217: 37-41https://doi.org/10.1016/j.ajog.2017.03.032
- Efficacy of the symptothermal method of natural family planning in lactating women after the return of menses.Am J Obstet Gynecol. 1991; 165: 2037-2039https://doi.org/10.1016/s0002-9378(11)90575-4
- Contraceptive discontinuation attributed to method dissatisfaction in the United States.Contraception. 2007; 76: 267-272https://doi.org/10.1016/j.contraception.2007.06.008
- Hertz-Picciott I. Measuring contraceptive effectiveness: A conceptual framework.Obstet Gynecol. 1996; 88: 24S-30Shttps://doi.org/10.1016/0029-7844(96)00251-7
- Fair inclusion of pregnant women in clinical trials: An integrated scientific and ethical approach.Trials. 2018; 19: 78https://doi.org/10.1186/s13063-017-2402-9
Article info
Publication history
Published online: June 14, 2022
Accepted:
June 5,
2022
Received in revised form:
May 26,
2022
Received:
January 10,
2022
Footnotes
☆Disclosures and Funding:Conflicts of interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.
☆☆Funding: Funding for the review was provided through a USAID contract. KNDR Healthcare, LLC provided in-kind donation (EK effort). KNDR had no role in the design of the project or review of the data or manuscript. USAID provided funding starting after the design of the project, the literature search, the abstract review, and the full-text review. They had no role in the design of the project or data analysis plan. USAID read the manuscript before publication and provided comments that the authors were not obligated to incorporate. The Keck School of Medicine of USC provided funds for this review through the Keck Summer Research Fellowship.
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
