• natural family planning

If you are a young female in the UK that uses social media (as 96% of 16–24-year-olds do),1 you may have come across an advert for Natural Cycles since they began their media campaign in late 2016, when using platforms such as Facebook, Instagram or Twitter. Natural Cycles is a ‘natural contraception’ app that was created by a Swedish particle physicist and her partner. For £39.99 per year, users log their body temperature each morning, and occasionally other details, such as their menstruation, and an algorithm determines their fertile days (during which the user would need to use barrier contraception or avoid sexual intercourse). It has been approved as a medical device for contraceptive purposes in Europe.2

The most recent study of the app was funded and primarily run by Natural Cycles. The study was a prospective observational study of 22 785 users who were mostly Swedish and had an average age of 29 (SD=5) years. They do not mention the previous contraceptive practices of their population. Women were considered pregnant if they reported it to the app, or if the timing of when they stopped using the app made it likely they were pregnant. With perfect use, Natural Cycles claims a failure rate of only 1.0 pregnancy per 100 woman-years. With typical use of the app, the failure rate increases from 1.0 to 6.8 pregnancies per 100 woman-years. However, less than 10% of the user data qualified as ‘perfect use’ and contributed to the analysis. If they included all women for which the pregnancy status was unknown (who could possibly be pregnant) this went up to 9.0 pregnancies per 100 woman-years.3 Although they acknowledge both ‘typical use’ and ‘perfect use’ figures in their marketing, they do not mention that very few women achieved ‘perfect use’.

A 2012 Cochrane Review evaluating fertility awareness as a method of family planning, stated that “the comparative efficacy of fertility awareness-based methods of contraception remains unknown […] contraceptive methods should be properly evaluated, preferably in randomized controlled trials, before adoption and dissemination".4 Natural Cycles has never been evaluated in a randomised controlled trial, the evidence is drawn from the prospective cohort study outlined above. The Family Planning Association have also called for more rigorous, independent research into fertility awareness based apps before they can be compared with other forms of contraception.5 Despite this, under the ‘science’ tab of the Natural Cycles website, the makers of the app invite comparisons between the app and the combined contraceptive pill/oral contraceptives, the intrauterine device, condoms, and natural family planning.2

Natural Cycles could also be more consistent in providing information around barrier contraception. They do advise on their website and in commercial partnerships with social media influencers that barrier methods do need to be used to protect against sexually transmitted infections; however, this is not mentioned in every marketing campaign, for example, a series of advertisements on Instagram which emphasise that women are only fertile on up to 6 days of their menstrual cycle, but do not contain any advice about barrier methods.

The approach adopted by Natural Cycles exposes the relatively weak regulatory environment around social media and advertising of contraception to the dissemination of partial information to potentially naïve and suggestible audiences. Currently, the UK Code of British Advertising requires all advertisements for broadcast media (television and radio) to go through a specific, rigorous clearance process. There are 34 rules specifically for medical devices and treatments, including not allowing well-known people to present the product.6 This stringent regulation does not apply to marketing on social media, which is self-regulated, and it is up to social media users to report to the Advertising Standards Authority content they think is incorrect or inappropriate. In the UK, it is not permitted to advertise prescription-only medication, which applies to most pharmaceutical contraceptives.7

It seems problematic therefore that advertising of an app like Natural Cycles is allowed, where it is not in relation to a number of more mainstream and better-tested contraceptive products and methods, with all that entails in terms of the public availability of information on the topic.

Natural Cycles heavily market their app using targeted advertisements on social media. In comparison to other population groups, young women who are regular social media users are most likely to trust social media content.7 Personal information such as search interests and political views are mined by advertisers to build up this relationship with their audience.8 This trust may be even stronger when it appears to originate from a person they can relate to rather than a brand. By engaging well-known social media stars with large followings (social media influencers) to promote their product, companies exploit the trust that individuals hold for people they admire online. Often influencers describe their transition from hormonal contraception to Natural Cycles and provide followers with a link to a discount code. One caption describes switching to Natural Cycles from "putting hormones in my body" as "probably best decision this year" and being "already happier". According to their website, within their large marketing department they have two employees with the job title ‘influencer manager’.9 One of the influencers they have chosen is a star of a reality television show that is very popular with young teenagers and so it is likely a proportion of their following is comprised of people under the age of 18 years, despite the age restrictions of the product (which are easy to bypass). One of the most popular YouTube videos posted by another 22-year-old influencer, with three million YouTube subscribers, shows how to create four ‘back to school’ hairstyles, implying that her audience is also younger teenagers. Users are then described as ‘cyclers’ in the app and in promotional material, which creates a pack mentality similar to the One Direction fans - ‘directioners’, and Justin Bieber fans - ‘beliebers’.

Using the app correctly is time consuming and requires heavy user involvement, possibly explaining the high discontinuation rate (54% at 12 months) and low proportion of women contributing to the perfect use analysis (less than 10%).3

Under the circumstances, we consider it is important that Natural Cycles’ marketing materials ought to be entirely transparent, more clear than they currently are about the limitations of their app and pregnancy risks, and consistent across the board about barrier advice, so as to enable women to make a fully informed choice. We also call for Natural Cycles to stop using social media influencers with followings comprising women aged under 18 years, or whose primary audience falls outside the age bracket or lifestyle of the women whose data formed the basis of their research.

The example of Natural Cycles draws attention to a wide range of problems and potential problems with commercial use of social media to market contraception including not only this use of ‘influencers’ and how information about reliability and effectiveness is reported, but also the need for more research to understand social media impact and how content is understood. According to business magazine Campaign, who awarded Natural Cycles its ’Pick of the Month', "50% of subscriber growth [was] attributable to marketing efforts on Facebook and Instagram".10 Natural Cycles have understandably and effectively taken advantage of a less-regulated arena with few competitors, which may lead some to question the adequacy of the regulation of social media and its role in advertising. For women that want to use natural methods and understand their reproductive cycle, this app offers an opportunity for empowerment and possibly the most effective method of fertility awareness tracking for contraceptive purposes, but commercial imperatives have arguably got in the way. Natural Cycles has the opportunity to stake a claim as the leading commercial operator in this field, but to do so it must ensure that it provides absolutely full and frank information about the efficacy and limitations of its products.