May 20, 2020
By Noopur Doshi

Editor’s Note: Fertility awareness applications (apps) are a hot topic and will continue to grow in popularity, making it essential to assess their effectiveness, accuracy, and ease of use. This is a review of research[i] published in 2018 in the International Journal of Gynaecology and Obstetrics titled, “Acceptability of a text message-based fertility awareness application for family planning in Lucknow, India.” It was written by fourth-year medical student, Noopur Doshi, as part of the two-week online elective taught at Georgetown University School of Medicine by FACTS co-founder, Dr. Marguerite Duane.

To learn the latest on apps and their use in fertility awareness, plan to attend our next bonus webinar, “What’s New with Fertility Tracking Apps?” Join us on Tuesday, May 26, 2020 at 8:30 PM ET and hear from researcher and FACTS Advisory Council member, Mike Manhart, PhD. You may register HERE.

Introduction

Although more than half of the 7.4 billion mobile subscriptions are from basic cell phone users (as opposed to smartphones), few studies explore non-smartphone-based fertility awareness applications (apps). To address the need for an app for use on basic cell phones, a fertility awareness application was developed that utilizes short message service (SMS) text messaging to assist with natural family planning (NFP)/fertility awareness. This app combines basic text messaging with an algorithm that can “learn” and better predict a woman’s cycle pattern based on data input over time. The goal of this pilot study in Lucknow, India was to evaluate acceptability and user satisfaction with this text message-based fertility awareness application.

Methodology

This observational study enrolled women who presented to the Sarathi Development Foundation in Lucknow, India for family planning support over a 3-month period in 2016. Women were educated about all available contraceptive methods and were invited to participate in the study if they had an interest in fertility awareness-based methods (FABMs)/NFP. The inclusion criteria were as follows: (1) reproductive age, (2) not currently pregnant, (3) able to read and speak basic English, and (4) able and willing to carry a mobile phone throughout the pilot period. The Stanford Program for International Reproductive Education and Services (SPIRES) developed the application for use on basic cell phones. All the data from study participants was stored in a back-end cloud database.

The application used the “calendar days” approach, which divides a woman’s menstrual cycle into three phases: a pre-ovulatory infertile phase, a fertile phase, and a post-ovulatory infertile phase. Through this application, users received automatic daily SMS text messages on their cell phones at a predetermined time indicating the status of their fertility. For instance, the participants may receive a message noting their status was “infertile” or “high fertility.”

After enrollment, all participants completed four hours of training, provided menstrual history from two previous cycles to inform their individual algorithms, and were given mobile phones with subscriber identity module (SIM) cards. During the 60-day study period, participants were contacted weekly to answer questions and assess their satisfaction with the application. All participant problems and questions were documented. Halfway through the study, a focus group was conducted to assess their overall experience, and further instructions about how to interact with the application were provided as a review for the participants.

At the end of the study, participants completed a paper survey focused on user satisfaction, feedback about the application, and family planning method preferences. They were also asked to participate in a final focus group.

Results

In this pilot study, 21 women ages 25 to 35 were enrolled. Of the 21 participants, 12 (57%) lived in Lucknow’s poor resource areas. 76% of the women reported current or prior use of a family planning method. Results were as follows:

  • 18 participants (86%) found it was easy or very easy to text menstrual cycle information
  • 16 participants (76%) reported it was easy or very easy to understand and follow the instructions given by the application
  • 19 women (90%) found it was easy or very easy to understand the daily alert message
  • 20 participants (95%) received daily alerts at the pre-determined time
  • 20 women (95%) stated they would be likely or very likely to recommend the application to friends and family

In the post-intervention focus group, all 21 participants reported the application was an effective way to track fertility status and a good method of family planning for them. They also reported a desire to continue using the application. They stated the messages are a “unique and simple source of information regarding fertility status” and “appreciated the privacy and convenience of being reminded of fertility status via mobile phone.”

Discussion

This pilot study has several strengths, including the population of women chosen for the research, as they are likely users of this technology beyond this study. The results show the application was highly acceptable to the users, who were very satisfied with the text message-based technology and felt it would be feasible to use this or similar apps in the future. The algorithm used in the application allowed personalization of messages to the participants, an approach shown in a meta-analysis to significantly increase the effectiveness of health-based interventions. Further studies with a larger sample size will be essential to assess how acceptable and feasible such text message-based fertility awareness applications will be.

Network coverage issues affected the application’s performance. This meant some participants were not receiving messages consistently. This setback was handled successfully by sending the SMS messages over a period of three hours instead of all at once. Given these technical issues, and to ensure the goal of 60 days of data was achieved, the program was extended by two weeks. Another limitation is the small percentage of women with menstrual cycles that fall outside the 15-45 day range used by the calendar method. This application would not be reliable for this subset of women.

This study shows the potential of SMS messaging to expand access to fertility awareness-based methods. This widely available technology holds promise to benefit rural or underserved communities by providing a convenient, effective, and low-cost method for women and couples to make decisions about their reproductive health. It could also potentially help reduce unplanned pregnancies in these and other communities.

Editor’s Note: Although this research demonstrated the ease of use of a mobile texting app to indicate a woman’s potential fertility status, it did not assess the effectiveness of the app for pregnancy prevention. While the authors state they use a calendar day approach to determine the fertile phase, both the calendar rhythm method and the Standard Days Method require either women have data from at least six previous cycles or regular cycles between 26-32 days to be able to use these methods. While ease of use may certainly increase the likelihood that women will use the app, it is vital to show it is effective in helping women achieve their family planning goals. Clearly, more research is needed about this promising tool.

References

[i] Lerma, Klaira, et al. “Acceptability of a Text Message-Based Fertility Awareness Application for Family Planning in Lucknow, India.” International Journal of Gynecology & Obstetrics, vol. 142, no. 1, 2018, pp. 104–107., doi:10.1002/ijgo.12488.

Author Bio: Noopur Doshi is a fourth-year medical student at the Brody School of Medicine in Greenville, NC. Upon graduation, she plans to pursue family medicine. She is interested in women’s health, and when she came across the FACTS elective, she thought it would be a perfect opportunity to enhance her medical education surrounding women’s health with FABMs. She appreciates that these methods not only help with family planning but also with tracking reproductive health, and reaching the root cause of various women’s health issues through a deeper understanding of a woman’s reproductive physiology.

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