Perspectives of Women who Choose the Billings Ovulation Method: A Review
By: Shyamsundar Ramasubramaniam
Director’s Note: The research article reviewed this week was published in 2023 in BMC Women’s Health and is titled, “Understanding the Perspective of Women who Use the Billings Ovulation Method.” [1] This focus group study explored reasons for choosing the Billings Ovulation Method as well as positive and negative experiences with learning and using this natural family planning or fertility awareness-based method (FABM). The research was summarized by Shyamsundar Ramasubramaniam, a fourth-year medical student who participated in the FACTS fertility awareness elective offered through Georgetown University School of Medicine.
Introduction
Fertility awareness-based methods (FABMs) of family planning involve tracking real-time physiologic changes and/or biomarkers to determine the fertile days within a woman’s cycle. A couple utilizing these methods can then plan intercourse around this fertile window based on their desire to either achieve or avoid pregnancy. The Billings Ovulation Method was developed in 1953 by Dr. John Billings and his wife, Dr. Evelyn Billings. Unlike FABMs that require detailed observation and characterization of cervical mucus or daily basal body temperature readings, the Billings Method is entirely dependent on the subjective feeling of cervical mucus at the vulva. Studies show the Billings Ovulation Method is effective for avoiding pregnancy, with unintended pregnancy rates after 1 year between 1.1 and 3.4% with correct use. [2] The study by Ayala-Ramirez et al [1] summarized below aims to understand the perspective of women who utilize the Billings Method.
“The Billings Ovulation Method … developed in 1953 by Dr. John Billings and his wife, Dr. Evelyn Billings … is entirely dependent on the subjective feeling of cervical mucus at the vulva.”
Methodology
Twenty women who had completed their training in the Billings Method 48 months prior to enrollment and who identified it as their primary family planning method were recruited into the study. Four focus groups were conducted virtually and transcripts of these sessions were analyzed for key themes.
Results
The key areas explored by the investigators were reasons for choosing an FABM, reasons for selecting the Billings Method specifically, and positive as well as negative experiences with learning and using the Billings Method. Among the focus groups, the main reasons for choosing an FABM included religious beliefs, wanting a “natural” method, concerns about hormonal birth control, and a desire to learn more about their bodies. Women in the focus groups selected the Billings Method specifically due to its ease, simplicity, and affordability. Positive experiences in learning and using the method included having an experienced and patient instructor and the method’s lack of “internal investigations.” The focus groups cited the learning curve and charting observations as challenges associated with the method.
“Women in the focus groups selected the Billings Method specifically due to its ease, simplicity, and affordability.”
Discussion
In this study by Ayala-Ramirez et al, religious beliefs were one of the primary reasons for women to choose an FABM for family planning. This is consistent with the demographic characteristics of the group, with 61% of the women being Catholic. [1] These women explained that FABMs were consistent with the teachings they received in marriage preparation classes at church. The thought that FABMs are a more “natural” method of family planning compared to conventional hormonal treatments was also a common theme among the women. Using FABMs does not alter the preexisting balance between hormones such as estrogen and progesterone nor does it involve invasive procedures such as the placement of an intrauterine device (IUD). This makes clear why they can be regarded as a more “natural” approach to family planning.
As with any medical treatment, hormonal birth control carries its own set of risks and benefits. Side effects from hormonal birth control, such as abnormal mood symptoms, were also cited as a reason to favor FABMs. Many of the women also expressed a desire to learn more about their bodies by utilizing FABMs. As these methods are based upon intentional observation of a woman’s physiologic changes throughout each cycle, women who are correctly taught and consistently utilize these methods are able to gain an intimate understanding of their bodies.
The method’s ease of use, simplicity, and affordability were the main reasons that led women to select the Billings Method out of all the FABMs. As a cervical mucus-only method, the Billings Method differentiates itself from many of the other FABMs. For example, the Marquette Model is a “sympto-hormonal” FABM that relies on an electronic hormone monitor that measures changing estrogen and luteinizing hormone (LH) levels to help determine a woman’s fertile days. [3] Users of the Marquette Model need to purchase this electronic monitor as well as test strips. The Billings Method, on the other hand, does not require any sophisticated equipment or high upfront costs to be used effectively. Even among other cervical mucus-only FABMs, the Billings Method is much simpler. The Creighton Model is one such cervical mucus-only method; it requires manual examination of cervical mucus stretchability. The Billings Method does not require this and only relies on the subjective feeling of mucus. This lack of “internal investigations” was commonly cited among study participants as another reason they preferred the Billings Method.
The women in the study also reported some challenges, including the learning curve and charting requirements. Even with its relative ease of use compared to other FABMs, the Billings Method still requires proper training in the method as well as a basic understanding of female reproductive physiology and the menstrual cycle. Some participants noted that recognizing the sensation at the vulva was challenging at first, but this became easier with practice. Proper charting of these sensations is a requirement of the Billings Method that some women found difficult. Similar struggles with the learning curve, understanding physiologic changes, and charting accuracy can be seen with many other FABMs. With proper instruction from an experienced, patient teacher and enough practice, these concerns often diminish over time.
“Even with its relative ease of use compared to other FABMs, the Billings Method still requires proper training in the method as well as a basic understanding of female reproductive physiology and the menstrual cycle.”
This study offers key insights into the perspectives of real women who have used the Billings Method. While studies to evaluate the effectiveness of FABMs are instrumental to guide clinical recommendations, studies such as this one offer insight to understand user motivations and challenges. Several key limitations of this study include the small sample size as well as the skewed demographic characteristics of the women recruited, which limit its generalizability. This study raises several questions about the sentiments of women who utilize this and other fertility awareness-based methods and is an area to explore further in future investigations.
References
[1] Ayala-Ramirez, M., Grewe, M. E., Kaiser, J., Kennedy, E., Winn, M., & Urrutia, R. P. (2023). Understanding the perspective of women who use the Billings Ovulation Method®: a focus group study. BMC Women’s Health, 23(1), 1-15.
[2] Urrutia, R. P., Polis, C. B., Jensen, E. T., Greene, M. E., Kennedy, E., & Stanford, J. B. (2018). Effectiveness of fertility awareness–based methods for pregnancy prevention: A systematic review. Obstetrics & Gynecology, 132(3), 591-604.
[3] Fehring, R., Schneider, M., Bouchard, T., Raviele, K, & Rodriguez, D. (2013) Randomized comparison of two Internet-supported fertility awareness based methods of family planning, Contraception, 88(1): 24-30.
ABOUT THE AUTHOR
Shyamsundar Ramasubramaniam
Shyamsundar Ramasubramaniam is a fourth-year medical student at Kansas City University in Kansas City, Missouri. He completed his undergraduate education at UCLA in Los Angeles, CA. He is pursuing residency in family medicine and is interested in community health.
