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On 29 August 2018, news broke of an Advertising Standards Authority (ASA) ruling calling for a Natural Cycles paid Facebook advertisement to be withdrawn.1 Natural Cycles is a fertility awareness-based (FAB) contraceptive app, which has caused unease amongst researchers and clinicians in the way it is marketed to the public. The concerns centre around a patchy evidence base being presented in a biased way, in an advertising environment simply not set up for regulating medical devices on social media, outlined by Hough et al in their Personal View article.2

After around half a million downloads of the app, five complaints triggered the ASA to review one particular Facebook video advertisement. The investigation concluded that the claims "Highly accurate contraceptive app" and, "clinically tested alternative to birth control methods", in combination with the "highly accurate" claim, were misleading, breaching four industry code rules, and the advertisement in that format was banned.

Millions of women have been exposed to that campaign already. Indeed 500 000 had installed the app on their phone by the time the story hit the headlines. While that particular advertisement was withdrawn, others remain online, tactically placed in the social media news feeds of fertile-age women. Expert review found the evidence base too weak to support a claim of the app being "highly accurate", yet the weaknesses in the evidence and how they translate to users trying to avoid pregnancy barely filtered into the news articles when the story broke. It is questionable whether the publicity given to the outcome of the investigation was adequate to rectify the effect of the claims widely made and found to be misleading. It remains unlikely that women who had seen the advertisement and may have consequently downloaded the app have access to unbiased information on the evidence behind it.

The paucity and limited validity of research on FAB contraceptive apps is not just limited to Natural Cycles. A literature search found fewer than a dozen publications on FAB contraceptive apps. In a 2016 paper, of 55 FAB apps that claimed to be appropriate for pregnancy prevention, only six could correctly identify the fertile window.3 A retrospective study concluding that the Daysy view app improves the typical use pregnancy index of the already established Daysy fertility monitor,4 has been described as "fatally flawed",5 and called to be withdrawn. There are significant incongruities between young women’s understanding and expectations of FAB contraceptive apps as "evidence based" and "scientifically proven" compared with the reality.6

The need for robust regulation with the aim of preventing rather than removing misleading information surrounding FAB contraceptive apps is critical. This Natural Cycles incident acts as a case in point of everything Hough et al described.2 Unfortunately, waiting for the ASA to investigate campaigns that have been live for some time in response to complaints is not watertight enough.