Physician Dispositions Towards FABMs: A Research Review
By: Laura Vanderheiden-Zahner, MD
Director’s Note: Despite the growing prevalence of fertility awareness-based methods (FABMs) in the general population, significant educational gaps remain, particularly among medical professionals. The study summarized below by a former FACTS elective student, Dr. Vanderheiden-Zahner, is titled, “Physician Dispositions Toward Noninvasive Non-Hormonal Contraception.” [1] Its lead author, Alexandra Davidson, also completed the FACTS elective, is a FACTS ambassador, and received an outstanding poster award for the research. In the study, Davidson and Butler explore present attitudes toward FABMs among physicians in Kansas and examine their knowledge and accuracy in conversations surrounding these methods of natural family planning (NFP). The study highlights the need for further integration of these methods in medical education. To learn more about reproductive health topics taught in medical school, read An Evaluation of US Medical Schools’ Reproductive Health and Family Planning Curricula, a 2022 study co-authored by our executive director, Dr. Marguerite Duane.
Introduction
Fertility awareness-based methods (FABMs) or natural family planning methods are rarely discussed in medical education. As a result, most physicians, residents, and medical students know little about these methods compared to hormonal contraception. The study by Davidson and Butler summarized below provides insight into this gap among physicians in Kansas. The authors employed a two-fold approach. They first assessed how often physicians offer FABMs as an alternative to hormonal contraception based on their opinions of these methods, and then examined physician knowledge of FABMs.
Methodology
This study was done via self-administered surveys of attending physicians and residents (MD or DO) who were contacted by email. Responses were analyzed from four different specialties, including obstetrics and gynecology, family medicine, internal medicine, and pediatrics. The survey was anonymous in an effort to reveal more accurate information and honest responses. Eight standardized multiple-choice or true/false questions assessed physician knowledge of FABMs. Physicians’ current practice style, opinions, biases, and ability to offer FABMs for family planning were assessed with 18 Likert-style questions, with some having optional free text response boxes. Answers to open-ended questions were compiled by theme while the answers to close-ended questions were analyzed statistically. [1]
Results
A total of 79 physicians completed the entire survey. Although 96 physicians started the survey, 11 of them were incomplete; answers from the partially completed surveys were included in the results. A key result from the study showed 60% of respondents recalled being taught about FABMs or NFP in medical school. In response to a question asking whether physicians had patients who used FABMs for contraception, 46% reported they did have FABM users among their patients, 33% were unsure, and 21% reported they did not have patients using these methods. [1]
When asked if they discussed FABMs as part of their contraceptive counseling, 42% of physicians responded “yes,” 24% answered “sometimes,” and 34% responded “no.” The physicians were asked to provide the correct range for typical use effectiveness of FABMs. According to the authors, the correct response per the CDC is 77 to 98%. Regardless of their counseling of patients, only 20 respondents (~25%) could correctly quote the typical use efficacy of FABMs in this study. However, of the 35 respondents who stated they always include FABMs in their contraceptive counseling, < 25% correctly identified the typical use efficacy of FABMs in the standardized questions. This led to the conclusion that these physicians may be educating patients with inaccurate data and explanation of these methods. [1]
“When asked if they discussed FABMs as part of their contraceptive counseling, 42% of physicians responded “yes,” 24% answered “sometimes,” and 34% responded “no.”
The most common reason cited by 15 physicians for not including FABMs in contraceptive counseling was the perception that these methods are ineffective. Other common reasons for not counseling patients on these methods were patient preference and/or values, poor adherence, unawareness of these methods, partner involvement, and the perception that they are unscientific. [1]
“The most common reason cited by physicians for not including FABMs in contraceptive counseling was the perception that these methods are ineffective.”
Given the data already discussed, it seems surprising that 97% of participants correctly believed cervical mucus could be a reliable marker of fertility. In addition, 96% of physicians were familiar with the changes in cervical mucus that occur throughout the menstrual cycle, and 99% were familiar with the basal body temperature changes inherent to the menstrual cycle. [1]
Discussion
Given that many methods have similar typical use effectiveness rates to hormonal contraception and barrier methods, it is imperative to share accurate information about FABMs. At the very least, factual information should be a part of medical education so students and residents are not left to seek out this learning on their own.
Davidson and Butler captured physician opinions, biases, and knowledge of FABMs through a variety of questions. Despite the small sample size comprising a small subset of physicians in Kansas, this research is interesting and informative. A similar study on a larger scale enrolling physicians from diverse areas and backgrounds with a larger sample size would be more generalizable across the United States.
This study had multiple strengths. The two-step questioning approach allowed for opinions and biases to be shared through Likert-type questions while knowledge of FABMs was tested through multiple choice and true and false questions. Statistical analysis could then be run on questions with a single correct answer while allowing the autonomy of self-disclosure related to bias, opinions, and practices of physicians related to FABMs. Another strength was comparing answers among four different specialties that may encounter scenarios requiring contraceptive counseling. Limitations include study results that are not broadly generalizable to a large population based on sample size and location of survey takers in a single university.
This study had some unexpected results and provides insight to inform future research. It is surprising that 60% of participants recalled being taught about FABMs or NFP in medical school. If a similar study was done on a larger scale, this value would likely be lower. It is also interesting that such a large number of participants realize cervical mucus and basal body temperature changes are signs of ovulation and fertility. Yet, despite this knowledge, participants scored poorly on questions about effectiveness of FABMs, revealing educational gaps that can impact patient care.
“It is interesting that such a large number of participants realize cervical mucus and basal body temperature changes are signs of ovulation and fertility. Yet, despite this knowledge, participants scored poorly on questions about effectiveness of FABMs.”
This study provides a foundation for many possible avenues for further research. The study focus could be narrowed to investigate physician knowledge of FABMs more fully. Alternatively, physician opinions, biases, and familiarity with FABMs stemming from their education could be assessed. To obtain a more accurate representation of what is currently being taught in medical schools, a study done prior to graduation could ask fourth-year students what they learned about FABMs while in medical school. Much research and learning should still be pursued in the field of fertility awareness and NFP, including specific FABMs and how each differs from the others. Studies reveal patients increasingly desire to learn about FABMs, leading to a growing demand for physicians to teach these methods. This desire and demand for evidence-based instruction will continue to rise as accurate information is shared with the general population.
References
[1] Davidson, A., & Butler, F. (2023). Physician Dispositions Toward Noninvasive Non-Hormonal Contraception. Kansas Journal of Medicine, 16(1), 94–104. https://doi.org/10.17161/kjm.vol16.18958
ABOUT THE AUTHOR
Laura Vanderheiden-Zahner, MD
Laura Vanderheiden-Zahner, MD is a second-year family medicine resident at Via Christi Family Medicine Residency in Wichita, Kansas. She completed her undergraduate education at the University of Kansas in Lawrence, Kansas. She has a passion for women’s health and pediatrics as well as care of the whole person which led her to choose family medicine as a specialty. Dr. Vanderheiden-Zahner enrolled in the FACTS elective to gain a better understanding of FABM’s and how to best share this knowledge with her current and future patients.
