BPAS data shows increased use of fertility awareness-based contraceptive methods

• Below – a new report in the British Medical Journal.
• We have also added the FPA’s view on the new report

Shift to ‘natural’ contraception methods among abortion patients over past 5 years

Use of the pill and implants has reduced as fertility awareness methods on the rise in England and Wales.

According to new research published in the journal BMJ Sexual & Reproductive Health – there’s been a shift away from more reliable hormonal methods of contraception to typically less reliable fertility awareness methods among women requesting abortion in England and Wales over the past 5 years.

The findings indicate the use of the combined pill, progestogen-only-pill, implants, patches, and vaginal rings has reduced while more patients report using hormone-free fertility awareness methods, such as period tracking apps that highlight monthly peak fertility/ovulation.

The researchers conclude that while further research is needed to understand the reasons driving these changes, the trends correspond to a rise in abortion rates, with wider implications for healthcare services.

Women may be increasingly reluctant to use hormonal methods of contraception

Worldwide, women seem to be increasingly reluctant to use hormonal methods of contraception, note the researchers. In 2010 around half of women of reproductive age in the UK were using the Pill, since then its use has steadily declined.

Anecdotal evidence suggests that women are increasingly turning to more ‘natural’ fertility awareness methods of contraception, largely influenced by social media, say the researchers.

But the typical failure rate for these methods ranges from 2 to 23 in every 100 women in the first year of use compared with 7 in 100 women for the combined and progestogen-only pill and less than 1 in 100 for the implant, hormonal coil and copper coil.

The numbers

To find out what contraceptive methods women requesting abortion in England and Wales were using when they became pregnant, the researchers compared data from the British Pregnancy Advisory Service for January to June 2018 (33,495 women) and January to June 2023 (55,055 women).

• Fewer young women (aged 25 or below) requested an abortion from a BPAS facility in 2023 than in 2018
• The proportion of women who had not had a previous abortion fell from 62% in 2018 to 59% in 2023
• The proportion of women of minority ethnicity rose between 2018 and 2023, as did the proportion of medical abortions requested
• The proportion of women who were at week 7 (or earlier) of pregnancy was significantly higher in 2023 than in 2018, rising from nearly 37% to just over 59%

Sizeable shift in contraceptive choices occurred between 2018 and 2023:

• Reported use of fertility awareness based methods around the time of conception increased from 0.4% of bpas patients in 2018 to 2.5% in 2023
• The age of those using fertility awareness methods fell from nearly 30 to 27
• The use of hormonal methods fell from just under 19% in 2018 to just over 11% in 2023
• The use of long-acting reversible contraceptive implants also fell from 3% to 0.6% over this period
• Those who said they hadn’t used any form of contraception when they got pregnant significantly increased by 14%, rising from 56% in 2018 to nearly 70% in 2023

Cause and effect?

This is an observational study, precluding firm conclusions to be drawn about cause and effect.

And the researchers acknowledge that abortion patients may not reflect the sexually active population in general. They also highlight that the precise fertility awareness method used wasn’t recorded, so the rise in the use of app technologies can only be assumed.

The researchers pointed out that:

“The shift in preference towards [fertility awareness methods] is coupled with reported increases in difficulty in accessing the more effective methods of contraception following the COVID-19 pandemic due to workforce changes and a reduction in primary care and sexual healthcare capabilities.

“The amalgamation of a shift in attitudes and difficulty in accessing certain methods has led to increasing use of less reliable methods. In turn, that has the potential to increase unintended pregnancies.”

“While the rise in abortion rates is multifactorial, one aspect that needs scrutiny is any change in contraceptive use – particularly this surge in the use of ehealth, including fertility apps, period tracker apps, and natural family planning apps.

“The possible relationship between these less effective methods of contraception and unplanned pregnancy requires further investigation. However, informing the public about the efficacy of such methods in order to facilitate informed contraceptive choices is needed.”

Lead Author: Dr Rosie McNee, Public Health, NHS Forth Valley, Stirling, Scotland.
BMJ report here

FPA response to the report by Bekki Burbidge, Information Specialist

Pinch of salt vs anecdotal evidence

As the researchers acknowledge – the data doesn’t give detail on changing habits / overall trends across the UK.

The data does highlight the habits of people “needing an abortion at British Pregnancy Advisory Service” and you would probably expect to see the less effective methods over-represented in the data.

Nevertheless, it probably does indicate that more people are using fertility awareness and that chimes with what we’ve heard anecdotally.

Underfunding Remains a Big Problem

Years of underfunding has made it much harder for people to access the full range of contraceptive methods.

There are now fewer appointments available and fewer health professionals trained in providing the most effective long-acting methods of contraception.

There certainly seems to have been a greater interest in fertility awareness-based contraceptive methods over the last few years.

This is probably for a range of reasons including:

• a lack of access to other methods,
• a shift towards wanting non-hormonal methods with fewer possible side effects, and
• the wider availability of fertility awareness apps

Less effective at preventing pregnancy

Fertility awareness-based methods can work well for some people but they’re typically less effective at preventing pregnancy than many other methods.

To be most effective they require:

• All partners to be committed to using the method
• An understanding of what makes them less effective, AND
• A commitment to using additional contraception or not having sex at certain times of the menstrual cycle

Although it can be hard to get an appointment, we do suggest that people consider talking to a healthcare professional for support with fertility awareness as it can take a while to learn to use it effectively and it won’t suit everyone.

It’s also important to know that hormonal contraception side effects can be positive as well as negative. For example, the hormonal IUD often means lighter and less painful periods.

How to improve

Having clear information about the effectiveness, advantages and disadvantages of each method of contraception is essential.

Likewise, improved access to contraception is vital – this needs to go hand in hand with investment in health services and a new national Sexual and Reproductive Health Strategy.

This is also why high-quality relationships and sex education in schools
is so important. With good RSHE everyone who needs contraception can make an informed decision about which method to use.