August 12, 2020
By Jessica Roberts

Editor’s Note: This article is one of several ways we are celebrating National Breastfeeding Month. This is a review of research published in 2017 in the Journal of Obstetric, Gynecologic & Neonatal Nursing titled, “Effectiveness of an Online Natural Family Planning Program for Breastfeeding Women.” It was written by a medical student, Jessica Roberts, as part of a two-week online elective taught by FACTS executive director, Dr. Marguerite Duane, at Georgetown University School of Medicine. The study highlights the versatility of a fertility awareness-based method (FABM), the Marquette Model, for breastfeeding women who wish to prevent or delay pregnancy during the postpartum period.


The use of natural family planning (NFP) to prevent pregnancy is often difficult for lactating mothers. Challenges arise in predicting the ovulatory fertile window, as often there are no “regular” cycles to depend on, and traditional signs of fertility can be convoluted. The Marquette Model (MM) incorporates the use of an electronic hormone fertility monitor (EHFM) which provides feedback about the estimated level of fertility on any given day based on urinary hormone levels (estrone-3-glucuronide and luteinizing hormone).

This study[i] by Fehring et al evaluated the effectiveness of the Marquette Model’s online, nurse-managed postpartum breastfeeding program among women seeking to avoid pregnancy. The study secondarily compared effectiveness rates to some qualifiers to method use. Specifically, they compared the rates of pregnancy among women who used either the electronic hormone fertility monitor, cervical mucus monitoring (CMM), or both to determine their level of fertility while breastfeeding.


This was a prospective and comparative cohort study. From April 2008 to June 2015, a total of 816 participants were compiled from registration in the Marquette Model online program, having indicated they were breastfeeding and then consenting to participate in the study. The website provided the online charting system, discussion forums, and women’s health information, including the protocol to follow for this research.

The study assessed the cycles recorded with the electronic hormone fertility monitor, via CMM, or both. Participants self-selected the subgroups. All unintended pregnancies that occurred were evaluated by professional nurses and assigned as either correct use or incorrect use.


Assessment of demographics revealed a largely Catholic, white, married, and well-educated participant group with a mean age of 30.3 years. For correct use over 12 cycles, the pregnancy rate was 3 per 100 users. The typical use 12-cycle pregnancy rate was 14 per 100 users.

The comparisons between the subgroups using EHFM alone, EHFM plus CMM, and CMM alone revealed correct use 12-cycle pregnancy rates of 3 per 100 users, 3 per 100 users, and 0 per 100 users, respectively. The 12-cycle typical use pregnancy rates were 16, 12, and 81 per 100 users, respectively; this showed a significant difference between the typical use of monitor groups compared to the CMM-only group.


This study found the Marquette Model online NFP program for postpartum breastfeeding women to be highly effective for avoiding pregnancy with correct use. Overall, it found a correct use pregnancy rate of 1 per 100 at 6 cycles of use and 3 per 100 at 12 cycles of use.

The study also demonstrated typical use pregnancy rates comparable to those of other FABMs, supporting the larger body of evidence for NFP methods. Reduced typical use pregnancy rates with the EHFM alone and the EHFM with CMM serve to update very frequently quoted rates from a 1999 study that assessed a CMM-only protocol for breastfeeding women.[ii] The EHFM subgroups in this study had slightly lower pregnancy rates in the first six months and higher adaptability than the Lactational Amenorrhea Method (LAM).[iii]

Typical use pregnancy rates from this study of breastfeeding women do not compare well to hormonal or intrauterine device (IUD) contraception methods.[iv] However, the study was aimed at providing data for women who may be seeking a natural method of family planning, which have no medical side effects that may interfere with the breastfeeding relationship. The authors feel that the degree of motivation for avoiding pregnancy influenced the increase of unintended pregnancy rates seen between 6 and 12 months of method use, which has been correlated in previous studies.[v]

Because of its recruitment process, the strength of this study is found in its effectiveness rates, which are based on interested users of the method. Yet, there were several limitations to this study and, thus, more studies are warranted. Future studies could consider a randomization process to overcome any selection bias, as well as recruitment of a more diverse group of participants. Developing a postpartum-specific charting system that accounts for amenorrhea would also enhance future studies. Further investigation into pregnancy rates in programs with scheduled follow-up, comparisons between in-person, online, or mixed instruction methods, and advances in technology such as phone applications would continue to provide useful data.


This study supports the efficacy of the online Marquette Model protocol with the electronic hormone fertility monitor for lactating mothers with correct use. This is a great, natural option for motivated women after giving birth and breastfeeding. As such, it should be included in any discussion of options for family planning during this challenging transition time.


[i] R. Fehring, M. Schneider, T. Bouchard. Effectiveness of an Online Natural Family Planning Program for Breastfeeding Women. Journal of Obstetric, Gynecologic & Neonatal Nursing, 46 (4) (2017), e129 – e137.

[ii] M.P. Howard, J.B. Stanford. Pregnancy probabilities during use of the Creighton model fertility care system. Archives of Family Medicine, 8 (1999), pp. 391-402.

[iii] A. Augustin, K. Donovan, E. Lozano, D. Massucci, F. Wohlgemuth. Still nursing at 6 months: A survey of breastfeeding mothers. American Journal of Maternal Child Nursing, 39 (1) (2014), pp. 50-55,

[iv] Trussell, J. Contraceptive failure in the United States. Contraception, 83 (5) (2011), pp. 397-404, DOI:

[v] R. Fehring, M. Schneider, M.L. Barron, J. Pruszynski. The influence of motivation on the efficacy of natural family planning. American Journal of Maternal Child Nursing, 38 (6) (2013), pp. 352- 358,


Author Bio: Jessica Roberts is a fourth-year medical student at Marian University College of Osteopathic Medicine in Indianapolis, Indiana. She participated in an FABM elective (Fertility Awareness-Based Methods for Family Planning) during her third year. She is interested in medical specialties that involve women’s health. She looks forward to incorporating FABMs into practice to foster appreciation and empower women and couples through an increased understanding of fertility.

FACTS 2-Day Virtual CME Conference
October 2-3, 2020

Modern Fertility Awareness for Women’s Health and Family Planning

After careful consideration, we have decided to postpone our one-day CME conference originally planned for July 11, 2020 in Baltimore, MD. The GOOD NEWS is we have changed the conference to a completely digital format and moved the dates to Friday, October 2 and Saturday October 3, 2020. We are looking forward to this event as an opportunity to connect with one another, learn more about fertility awareness, and to share all we have accomplished together.

As interest in FABMs increases, it is important that YOU are well-equipped with the latest research to inform women. Join us to expand your toolbox and be better prepared to counsel women about FABMs so they may make more informed healthcare choices. Learn more and register today!

We hope to “see” you there!

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2020 Back-to-School Fundraising Campaign

August 17-31

Our BTS Fundraising Campaign kicks off next week and we invite you to join us!  Our robust programming couldn’t exist without your support. Your partnership is essential to the FACTS mission as we work to fill the gap in medical education about evidence-based, natural or fertility awareness-based methods (FABMs).

Donate TODAY or stay tuned for more information on how you can help FACTS build better healthcare for all women!

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