Fertility Tracking Must Be Grounded in Evidence and Reproductive Justice

Fertility awareness-based methods (FABMs) are different approaches to tracking fertility and identifying which days someone is most likely to conceive if they are having sex without contraception. These include features such as tracking one’s menstrual cycle, basal body temperature, and cervical mucus, among others. Chelsea Polis, Principal Research Scientist at the Guttmacher Institute, sits down to talk with us about different FABMs, their effectiveness, advantages, and disadvantages, and why it is necessary for each method to be rooted in scientific evidence and reproductive justice.

By tracking these markers, someone can choose to have sex for the purposes of pregnancy or abstain from sex/use additional contraception methods if they seek to avoid pregnancy. Based on their advantages and disadvantages, FABMs may work for some individuals and not others. Some people use FABMs for contraceptive purposes, yet not all of the methods have been tested for that purpose or approved by any regulatory body for that use. Some methods are engaging in inappropriate marketing as a contraceptive tool, when it is not backed up by science or regulatory approval. FABMs have also become a piece of the Make America Health Again (MAHA) movement, being touted as a substitute for the full spectrum of reproductive care.

To best integrate FABMs as a contraceptive option into the full menu, we need to support providers, fund research, and combat misinformation.

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Fertility Tracking Must Be Grounded In Evidence And Reproductive Justice

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Transcript

Jennie: Welcome to rePROs Fight Back, a podcast on all things related to sexual and reproductive health, rights, and justice. [music intro]

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Jennie: Hi, rePROs. How's everybody doing? I'm your host, Jennie Wetter, and my pronouns are she/her. So, y'all, when you are hearing this, I am going to be at a conference for the National Family Planning and Reproductive Health Association, a collection of Title X providers. So, I'm very excited to see everyone and have a booth at the conference to get to talk about the podcast and all of the great work that rePROs does. I will get to see friends in the domestic community that I unfortunately don't get to see in person very often. So, I am very, very excited for the conference. Kicks off over the weekend, so I'm recording this early. And also, my birthday is this weekend. So, I'm actually going to be celebrating it at the conference. So, I have a lot to look forward to for the weekend, other than the fact that I only have Saturday off. That is a bit of a bummer, but that's okay. Like I said, I'll get to see a lot of friends and get to talk about sexual and reproductive health with providers from around the country, get to hear about things that they would like us to talk about on the podcast or issues we should be covering. I always find NFPRHA and getting to talk to all of the people there a really useful tool for guiding some of the things we need to talk about on the podcast. So, I am very excited. I don't really have anything special planned for my birthday since I'm going to be at NFPRHA for my birthday. But I did kick it off early by getting cupcakes sent to me by my office, which was very sweet. Thank you, everybody. The downside, though, is they came during my interview today. Which would have been fine because I knew that was the delivery window, and I had gone down and work out- let the front desk guy know, could he please accept them and or send the guy up to have him put him outside my door and then just not knock, so it wouldn’t interrupt my interview. And I don't know, the delivery guy called while I was in my interview. He couldn't find where he needed to be, and then the front desk guy wasn't there. Anyway, I had to freeze, pause the interview in the middle and go down and get the cupcakes, which were delicious and very exciting to have. But yeah, it just threw the groove off a little bit since I had to run and go get cupcakes in the middle of the conversation. But Chelsea rolled with it and it was all good. And there were delicious, delicious cupcakes that I am still enjoying that to be had after. So, very exciting. Let's see, I don't know that I have a ton else going on.

I think the one important flag is that we talked about the Global Gag Rule on a recent episode. If you want more information, please go listen to that episode to get a much more in-depth guide on it. The new rules that were proposed around it or were finalized around it, were attacking not just abortion, which had been traditional in previous iterations of the global gag rule, but was expanded to impact the trans community and DEI. And both of those are really wide expansions and can have really long-ranging impacts. Definitely listen to the episode where we do the deep dive into it if you haven't heard it yet. But anyway, all those three rules went into effect last Thursday. So, we are now living in a world where the Global Gag Rule is in effect, or this new terrible, terrible expanded version of the Global Gag Rule was in effect. Yeah, just terrible. These new attacks on these new communities and new donors and implementers, and just really wide-ranging and terrible. But yeah, it is now officially in effect. Well, that's kind of a bummer to end on. Let's turn back to my birthday and something fun.

I don't really have anything exciting planned, like I said, but if you want to show some birthday love to me, why don't you go and buy some rePROs merch? We have fun stuff on our site. I just bought myself a water bottle, so I'm very excited about that. I didn't have one of our water bottles yet. But yeah, if you go, we'll have the link in the show notes. But also, if you go to Bonfire and look for rePROs Fight Back, you'll find all of our fun merch. I really love all of the designs we have and the products we have, so definitely check it out. If you want to show rePROs some birthday love, or you can feel free to donate or leave a review. I would love either.

So with that, let's turn to this week's interview. I am very excited about this week's interview. Chelsea and I have been talking about doing an episode for so long, and we've had false starts of trying to schedule one for so, so long. And I'm so excited that it has finally happened. I am talking today to Chelsea Polis with the Guttmacher Institute, and we are talking about fertility awareness-based methods of family planning and why any conversations around FABMs need to be rooted in evidence and reproductive justice, and that they have just been lacking as part of the conversation for so long. So, I am very excited for today's conversation with Chelsea.

Jennie: Hi, Chelsea. Thank you so much for being here today.

Chelsea: Hi, Jennie. Thank you for having me. I'm excited to join you and grateful for all that you do for our space.

Jennie: Oh, thanks. We have been talking about making this happen for so long. So, I'm just so excited that we are finally having this conversation.

Chelsea: Me too.

Jennie: But before we dig in, maybe let's take a second. Would you like to introduce yourself?

Chelsea: Sure. My name is Chelsea Polis. I'm a Principal Research Scientist at the Guttmacher Institute, where I primarily focus on international research in sexual and reproductive health.

Jennie: Awesome. I am really excited because this is a topic one we haven't really talked about on the podcast before. And I think it gets a little bit of- it's not talked about a lot in our movement, I think, in general.

Chelsea: Agreed.

Jennie: As well. So, because of that, before we dig into the full topic we're talking about today, I think we need to do a little baseline, so people understand what we're talking about. So, what are fertility awareness-based methods?

Chelsea: Yes, yes. I'm glad we're starting from the baseline. This is, I fully agree, an under-discussed topic and one that needs a lot of background for a lot of folks. So, I'm glad we're starting here. So, fertility awareness-based methods, and as you'll hear me call them, FABMs, are basically different approaches that people can take to tracking their fertility and to helping those people identify which days of their menstrual cycle they're most likely to conceive if they have sex without contraception. And so, the fundamental biological principles operating here are really that pregnancy can only occur within a very specific window of time each cycle. It's roughly six to nine days biologically, and that window is sometimes called the fertile window. And what makes a method, a fertility awareness-based method, is that it relies on tracking one or more fertility biomarkers or basically fertility signs that show up cyclically each month. And so, these are things like tracking when your period starts, taking your basal body temperature every day, tracking changes in your cervical mucus to look at differences in color or consistency or texture throughout the cycle. Sometimes people feel for the position or texture of their cervix itself. And then sometimes people can track hormone markers in their urine, like Luteinizing Hormone using home test kits. And the whole idea, and actually some newer methods are starting to explore tracking progesterone in saliva. So, these are all different kinds of biomarkers used in different kinds of FABMs. And the whole idea is that by tracking these signs, users can try to identify that fertile window. And if they want to avoid pregnancy, they can either abstain from penile vaginal sex during those days, or they can use another method like condoms or another barrier method during that time if they're trying to avoid it. If they're trying to achieve pregnancy, they can use that information about their fertile window to try to time sex to optimize the chances of conception. So, one thing I want to be really clear on, too, that's often a point of confusion. FABMs are not the rhythm method. They're not the same as periodic abstinence, though those terms are often used very interchangeably. There's actually over 14 different FABMs that have been studied for effectiveness. They're all very different. They all use different biomarkers, they all use different rules for interpreting those biomarkers, and they all have different characteristics and effectiveness rates. But a lot of people seem to often assume when we talk about FABMs that we're talking about rhythm. So, just to kind of give a couple examples of some of the non-rhythm FABMs that we're talking about. There's the standard days method, this is one that only uses menstrual cycle tracking, and it works for people only for people who have regular cycles. There's the two-day method, which is a very simplified method based on observation of cervical mucus. There's Sensiplan, which is a symptothermal method that combines multiple fertility signs. There's the Marquette Method, which is one of those that uses those urinary hormone monitors. And then there's natural cycles, which is an app-based method that basically uses an algorithm to interpret information that users put into the app. Those are just a small sampling of some of the FABMs out there, not an exhaustive list, but hopefully starts to give listeners a sense of the variety of methods that are out there. And that last example that I shared is really where things have started changing quite a lot within the past couple of years. We're seeing an explosion of these kinds of digital approaches—so, apps, wearables like smart rings that track temperature or other devices that track fertility. And all of these technologies coming out, two, only two are FDA cleared for contraceptive use. So, that's only Natural Cycles and Clue Birth Control. And Clue is not currently on the US market. But all these other technologies are out there. They're generally kind of meant just for cycle tracking, knowing when your period is coming. But some people are nonetheless using them for contraceptive purposes, often without realizing that some of these technologies haven't been appropriately tested for that purpose or approved by regulatory bodies for that use. And then in some really bad cases, which I've dealt with pretty directly, manufacturers of some of those technologies are inappropriately marketing them as being for contraceptive use, even without having the right science or the right regulatory approval. And that's putting people unknowingly in harm's way.

Jennie: Yeah, I mean, the cycle-tracking apps are really helpful for just that, right? Tracking your cycle. Like it was really helpful for me personally, “oh, I noticed that always around this time in my cycle, this particular thing happens. I didn't realize that was related to my period or where in my cycle I was. I just thought I had some stomach problems and like whatever. But like, oh, this is when this happens every month. And okay, now I know. And so, it has been really helpful for things like that. But yeah, I don't use them for birth control because one, that's not what the one I use is for. But I always flash back to where you talked about people confusing them with like the rhythm method or whatever. And I talked about going to Catholic school, K through eight, I had sex ed from a nun. So, obviously, like that was as much as we were taught anything, I useful isn't even the right word because there was nothing useful. Like they talked about regular birth control, kind of, in that it doesn't work and all those things. And like mentioned like rhythm or something, but not it wasn't like taught. Yeah. It was just, like, you could do this.

Chelsea: Yes.

Jennie: But we're not gonna tell you how to actually do it.

Chelsea: Well, and that's one of the wild things about rhythm is when you actually read up on the method itself, there's these very stringent rules for it. You have to have your menstrual cycle start dates for your last six or more cycles, and then there's this series of very complicated calculations that you have to do, and it's very involved. But the actual way that the word "rhythm" is used in society is very elastic.

Jennie: Yeah.

Chelsea: And it might mean something all the way from doing all those complicated calculations and adhering to the rules to I feel like I'm fertile on Tuesdays and like everything in between. And it's made the conversation around these other kinds of FABMs even more complicated because I think understandably so, people view rhythm in one way, and they don't necessarily understand that some of these other approaches are different. And I think as we'll hopefully get into a little bit, I don't think our field has done conversations on this topic many favors.

Jennie: So, like you said, so much of the conversation around contraception and the ways people use to plan their families... FABMs aren't necessarily talked about a lot within our movement. What is the prevalence? Like, what are we seeing for how much it is used in the US?

Chelsea: Yeah, a lot of people ask me about this question. So, I'm glad you're raising it. And it's it's something I've done a lot of research on. The last paper I published on the United States, FABM prevalence in the United States, used data from 2013 to 2015. So, it's about a decade old, those estimates. In that paper, we found that about 3% of contracept-ing women in the United States were using an FABM. And that sounds a bit small, but it's more than that. It is. It's more than we're using the contraceptive ring, for example. So, it's over a million people, and that's a decade ago. And I say that obviously in the context of what's happening now. There's a lot of conversations happening around concerns around hormonal contraception, particularly on social media. There's all this technological development, as we just talked about, of this explosion of these kind of Femtech devices. And so, the big question now, I think, is: what does FABM prevalence look like today in the United States? I am actively working on this. My colleagues and I are using a lot of different data sets in the United States to assess this. And I can't share our preliminary results yet, but I will say that I believe this landscape and how much use of these methods are happening is changing a lot and changing fast. And I don't think our field has been tuned in enough yet to what's actually going on. And that gap in our understanding is something I've been trying to hammer away at for about 15 years. And a lot of folks in our field kind of used to look at me a little bit cross-eyed for wanting to do science on these methods. But I think it's starting to make a little bit more sense now, given the confluence of this tech explosion, the interest in these methods, some of the backlash against hormonal methods, and also, as I think we'll talk about today, the kind of politicization of these methods that we're starting to see.

Jennie: Yeah, that also makes me think some of like what we were just talking about, of people using the rhythm method and not having clear meanings on that. And so, it may mean different things. So, it also makes me think, like, surveying if people are using some of these FABMs, unless you're, like, really specific. And even then, people may have, like, different interpretations. Like, I can just imagine that makes collecting data really hard.

Chelsea: I actually didn't even go into that whole point, but I love that you're picking up on that, Jennie, because measurement of FABMs has been done, I think, in ways that we could improve upon enormously. Part of the paper that I mentioned about where we found the 3% was actually methodologically all about how do we get, how do we start getting to better measurements of these methods? Because we've historically underestimated them. And I've shown that with colleagues both in the United States and in Ghana— and I'm actively working with colleagues now, including Dr. Rebecca Simmons and others, on projects to improve the measurement of how people use these methods, why they use these methods, but in part so that we can get an understanding of how common this use is. Because exactly as you say, some people are using these approaches but wouldn't necessarily call it contraceptive use. They might refer to it just as kind of a practice that they do. And so, how you bring people into surveys where you're asking about contraceptive method use is a whole other interesting conversation that we could delve into if folks want to get really nerd nerdy about it.

Jennie: Okay, so before we go down into that super, like, definitely could have longer conversations, but maybe let's turn to: every method has its advantages and disadvantages. What are some of the advantages and disadvantages of using an FABM?

Chelsea: So, I think the biggest question I get when I talk about FABMs is how effective are they at preventing pregnancy? That's a huge and important question. Whether an FABM is effective really depends on the specific method and how it's used. So, we did a systematic review on this back in 2018, and we're actually updating it right now with new evidence, so there'll be a new one out, hopefully soon. And we looked at all the available evidence on how effective different FABMs are. And what we found is that both the quality of the evidence and the effectiveness varies a lot from method to method. So, there's some methods like SensiPlan and the Marquette Monitor that had moderate quality studies. So, those are better than low quality, but not quite high quality. But nonetheless, that's the best that we have, suggesting pretty high effectiveness. The typical use pregnancy rates were between about two to seven pregnancies per 100 women in the first year of use. So, that's in the same ballpark as typical use of something like an oral contraceptive pill or a patch or a ring. For most other FABMs, typical use effectiveness is lower. So, we're talking about 10 to 34 pregnancies per 100 women in the first year of use. That's more in line with something like condoms or sponges or diaphragms. And I really want to emphasize that those estimates, they're coming from studies where participants might be more highly motivated. They're showing up for a clinical study in some cases, and so they're having regular interactions with staff, they have enough stability in their life to participate in a long-term study. So, that might mean that the estimates are a bit more optimistic than in a general population. And our understanding is based on this small number of moderate quality studies for each individual FABM. So, if more studies come out, if better studies come out, it could change what we know about FABM effectiveness. But I think oftentimes people are surprised to hear that some of these methods have evidence that does suggest that some of them used in certain populations and under certain conditions have effectiveness that is in line with some other much more commonly known and perhaps accepted methods.

Jennie: That is always, I mean, that's something that people definitely need to know. You can't make good decisions about your sexual and reproductive health if you don't have all the information. So, that effectiveness is a really important part of that. But I'm sure there are other advantages and disadvantages when it comes to using an FABM.

Chelsea: Absolutely. Like every other method, every other contraceptive method that exists, FABMs have both advantages and disadvantages. So, in terms of advantages, a major one is that FABMs have no side effects. They might appeal to people who prefer not to use methods that involve devices or hormones, and that matters to a lot of people. Some are concerned about side effects; some have medical contraindications to hormonal methods. And for folks like that, FABMs can be an important option. Another advantage is that by encouraging fertility awareness, these methods, for some people, kind of incorporate what some people call "body literacy." So, a nice example of this that I sometimes raise is some providers have shared anecdotes that some patients came to believe that seeing normal vaginal discharge in their underwear meant that they had an infection. And then they learned about cervical mucus and kind of the cyclical nature of cervical mucus throughout the cycle and came to understand no, this was a sign of having a normal cycle, certainly not a sign of infection. So, these methods, I think for some people, help them feel more connected to their body and understand their cycles better, and they may find that empowering. Another aspect some people really like is that FABMs, as we talked about a little bit before, can be used to achieve or avoid pregnancy. Most other contraceptive methods kind of work in one direction, but FABMs give you this information, and then you choose, according to your fertility desires, what you're gonna do with that information. And then another advantage worth mentioning is that while not all FABMs are practiced in a religious context— many secular folks use them— these methods, some of these methods, not all of them, are compatible with the teachings of some major religions. So, for people in certain faith traditions, these methods might align with their personal values in a way that other methods don't. And obviously, religious folks deserve options just like anybody else. So, those are some of the advantages as I see them. And then to the disadvantages, as I mentioned earlier, FABMs are highly user dependent. They are very unforgiving of incorrect or inconsistent use. And that's because when they're used correctly, unprotected sex, by definition, is occurring on one of those days most likely to be fertile. So, that can mean higher typical use pregnancy rates than for some other contraceptive methods. They also require either abstinence or use of a second contraceptive method, like a condom during that span of time that's a prop that's identified as fertile. And we talked about the biological fertile window, which is six to nine days, but many of these methods put some cushion around the start and end of that window to increase effectiveness, and that means your method might be asking you to abstain or use a condom during up to half of your cycle or more, and that's not gonna fly for every couple. Another potential disadvantage, certain medical or lifestyle factors, things like a regular sleep or working the third shift or traveling across time zones, some of these things for certain FABMs can complicate their use, as can certain medications, which may impact some of your biomarkers. So, things like using an antihistamine can impact your cervical mucus and make use of that method during the time you're using that medication more challenging. And then similarly, there's some methods that only work for people with regular cycles. So, folks with PCOS or perimenopausal or breastfeeding might not be in an appropriate situation to use an FABM, although there are some FABMs that can be used if you don't have a regular cycle. That's another kind of common misunderstanding. And then another disadvantage, I think, like all non-barrier contraceptive methods, really like anything other than a condom, FABMs provide no protection against HIV or other sexually transmitted infections. And that's particularly important for folks who may have multiple partners or whose partners have other partners. And then there's two final kinds of characteristics to FABMs that I would say I can't classify as an advantage or disadvantage because it's really up to how the person views it. So, for example, the importance of partner participation. For some couples, that's great. They use this as a way to talk about each other's bodies and to communicate about when the timing and circumstances of sex are right for them. That can be really hard to achieve in certain partnerships. If you're in a couple where negotiating around the timing of sex or the use of condoms isn't possible, these methods are not going to be able to prevent pregnancy for you. And then the second one kind of depends on who you are, whether you see it as an advantage or disadvantage, is the extent of action required to use these methods. Some people love tracking every aspect of their health and their fertility signs and drawing up their charts and looking at them, and other people want something that's set it and forget it, and I don't want to think about it, and both of those are fine. It really just depends on what your preferences are. So, FABMs are legitimate options for the right person in the right circumstances with good information and support. They can fit into some people's values and lifestyles, but they're not right for everybody. And I think we need to be honest about both the advantages and the disadvantages.

Jennie: So, we've kind of teased this a little bit, but how have FABMs become part of this the MAHA movement and like what we're seeing online?

Chelsea: Yeah. A large and complicated question for which no single correct answer-

Chelsea: Real simple, easy answer.

Chelsea: Right. I will share how I see what happened, and I'm gonna start. Sometimes it's really good to start by reflecting inward. And here I'm gonna ask our field, our beloved field of sexual and reproductive health, to look inward, and then we'll get to dealing with the MAHA mess. But as we've talked about before, many people in the reproductive health and family planning communities, in my view, and it sounds like yours, have ignored or sidelined or even ridiculed these methods and the people interested in these methods, right? Providers often lack training on FABMs. We've seen this in studies. Many underestimate their potential effectiveness or just assume that they're not appropriate for certain people. And researchers have deprioritized studying them. I alluded to this previously. Okay, so then you have these methods deprioritized, so we wind up with less evidence on FABMs compared to other contraceptive methods. So that means providers are less well informed, may kind of brush them off, call them, oh, that's just Russian roulette to people who are interested in them. And when patients come understandably concerned about certain side effects and have questions about potential side effects or are otherwise just interested in learning about FABMs, when they encounter that kind of dismissal, whether it be from providers or folks in the research space, where do we think those people are gonna turn? They're gonna turn to their friends, they're gonna turn to social media. And as we know, on social media, as we've seen in studies, fear-based messaging about hormonal contraception is rampant. Misinformation spreads easily. And FABMs in particular, and we have studies showing this, are often promoted with really cherry-picked evidence that exaggerates their effectiveness and distorts whether these could actually meet an individual person's need in all cases. And influencers can kind of put these extreme views out there. Science doesn't always offer simple answers. Sometimes we have limited sets of studies with moderate quality evidence, so we have to be very nuanced and a little bit boring in how we talk about these methods. And so, it just creates this space for louder, and more profit-driven sometimes voices to fill that gap of certainty. And so, that's phase one as I see it. And I think that that dismissal in our field created this vacuum, which is now very eagerly filled by conservative influencers and policymakers who are seizing on FABMs to advance a much broader agenda. So, we're seeing this play out here in the United States with the MAHA movement and their kind of interactions with the folks behind Project 2025. These groups are promoting FABMs while simultaneously working to restrict access to other contraceptive options, to abortion, to certain kinds of fertility and infertility care, all while slashing funding for programs like Medicaid and SNAP that help people raise their children. So, it's kind of hard to be any further away from the concept of reproductive justice than these kinds of actions. How can you talk about family values while you're cutting SNAP and Medicaid, which families actually need to raise children? I'm not sure. But we've seen in Project 2025 calls for CDC to message about the quote, unsurpassed effectiveness of modern FABMs. And this is just untrue. There are some other contraceptive methods that are more highly effective at preventing pregnancy than any FABM. And it's important to be clear about that. And it's important to be clear that effectiveness is only one of many factors that impact people's contraceptive decision making. So, that's how I see this has kind of come about. There's nothing inherently political about FABMs, they're just another option. We should treat them that way. But these methods are being politicized, I think, to push a particular agenda. And I think that agenda is being pushed in some pretty effective ways. Some influencers are using language around wellness and natural and empowerment and reclaiming your cycle. And don't- those messages are very appealing and they're tapping into something real that people do experience. Some people do experience side effects from hormonal contraception. Some people do want more natural, hormone-free options. And some people feel that the medical establishment has dismissed their concerns. And so, MAHA is taking a lot of these legitimate concerns and kind of weaponizing to push an agenda that restricts access to all reproductive care. So, it's a strategy where FABMs are kind of being elevated not as one option among many, but as a substitute for the full spectrum of reproductive care. And the message there is kind of you don't need hormonal contraception, you don't need abortion access, you don't need Title X clinics, you don't need IVF, you just need to track your cycle. And some folks may be genuinely interested in FABMs for very legitimate reasons and not necessarily realize that they could be pulled into a movement whose ultimate goals are quite antithetical to reproductive autonomy.

Jennie: It's interesting because I can see the different threads of our conversation like coming together. So, seeing how easy the different forms of FABM and rhythm method, and all those get conflated and people think they're the same thing.

Chelsea: Yes.

Jennie: And thinking about how it gets downplayed in our movement, I think some of that is like the like I can look inside myself and see it as like the backlash to the lack of sex education I was given. And that I was given these really unhelpful tools and told that condoms didn't work or that birth control didn't work and all these things. And so, my internal backlash then is to make sure that people are getting accurate information about these methods. And so, in my head, doing that conflating of the FABMs and the really ineffective things that I was taught happens easily. And then, like, we shouldn't focus on that. We should just focus on these really effective things. So, I think there's a lot of that happening because sex ed is so bad everywhere right now. And a lot of what we all came up with was not great. So, you can see easily how that happens, just the same way you can see the easiness with some of these influencers and like pushing methods and not talking about like focusing on the wellness aspect, but not talking about like the details and like why it's complicated and that you need to really know all these things in order for it to be really effective. And again, then people aren't getting accurate information, which I think leads really easily nicely into this great piece you wrote in health affairs, talking about the need to center these conversations in evidence and in reproductive justice. Let's talk a little bit about that.

Chelsea: Yeah, thank you. Thanks for your kind words on the piece. It was good to get it out into the world. I feel like it's been the message that's been building in me for a long time, and it felt really great to have it out there and see people's reactions to it. So, to start with, sure, I think most of your listeners probably know, but it talks about Reproductive Justice. And to start there, Reproductive Justice was conceptualized by Black women in 1994, and they really articulated that reproductive freedom isn't just about the legal right to abortion or contraception, it's also the social, political, economic power and resources to make decisions about our bodies, our families, our futures. And it centers the right to have children, the right not to have children, and the right to parent children in safe and supportive environments. And it also really centers the experiences of the most marginalized communities. I think FABMs, not only by nature of the fact that I love the little parallel with they can be used either for avoiding or achieving pregnancy, which fits quite well with the first two tenets that I mentioned, I think FABMs really fit in a reproductive justice framework when and only when people have access, as you're talking about, to accurate, evidence-based information about all of their contraceptive options, person-centered non-judgmental counseling, the ability to choose from a full range of methods. I would add in a well-functioning regulatory system, especially now that we get into some of these tech-based methods, access to abortion care if a method fails, access to information about how to avoid infertility and access to treatment options to address infertility, and the social and economic support for whatever reproductive decisions they make. And so think about those pieces and notice what's missing from the MAHA vision. Mostly all of that. So, yeah, so the piece, it was published in health affairs, and it really talks about what needs to happen to center FABMs in evidence and in reproductive justice. And so, from the evidence side of that, part of it is funding rigorous research on contraception, including FABMs. We have a fair amount of industry-funded studies on these methods, I think, in part because we haven't had funding for independent researchers to look at these methods. So, we need rigorous peer-reviewed research in diverse populations on newer technologies, about user experiences and preferences and effectiveness and counseling effectively and all kinds of things. And I will note here one thing that I am particularly proud of. I mentioned earlier the systematic review that we did on FABM effectiveness. In that review, we used a model called oppositional collaboration, and I talk about this a little bit in the piece as well. What oppositional collaboration means is that researchers from across the ideological spectrum, people who disagree vehemently about abortion and contraception, came together around a shared commitment to rigorous science and worked alongside each other to produce evidence using our collective biases to sharpen each other's focus on the data. And we produced evidence that CDC then cited in updating their contraceptive guidance. And that's ideally how it should work following the data, not the ideology. So, that's kind of on the evidence side, I guess I would also put in their provider training. We need to support providers who are massively time constrained to figure out the best ways to either be able to counsel or refer people who are interested in FABMs in ways that are accurate and not judgmental. They need to be able to say, these are an option. Here's what the evidence shows, here's the advantages and the disadvantages. Let's talk about what's the right fit for you and not say, that's just contraceptive Russian roulette. That's not gonna help people get to where they need to be to have the information they need to make choices. I talk a little bit in the piece also about what needs to happen kind of on the regulatory side. Right now, there's so much gray area in how these technologies are being regulated. And I think that's an area that's ripe for a lot of work. And then just combating misinformation, as we talked about before. There's so much misinformation out there. And we often talk about it on social media, but I think we've alluded here to misinformation within our own spheres sometimes that we also need to be open to addressing when there are different ways that perhaps our field should be thinking about particular topics. So, end of the day, I think the piece really speaks to the need for FABMs to simply be integrated into the full menu of contraceptive options, not as a substitute for other options, not as something that should be elevated above anything else, but as one option among many and with honest information provided about it.

Jennie: It seems so basic.

Chelsea: Doesn't it? Doesn't it? I agree.

Jennie: Just I feel like I could talk to you forever about this, and I'm sure about many other things, but I want to be cognizant of your time. So, we always like to end focusing on: what can the audience do to get involved? And maybe this one is a little different, and maybe we want to do like what do you want the audience to take away? Like what should they know about this going forward and in their conversations?

Chelsea: Thank you. Yeah, that's a great question. I would start as a researcher, as somebody who's really into the data and the science on all methods of contraception, including FABMs, know the evidence. Not all FABMs are equally effective. If you're interested in these methods, ask questions. What's the typical use failure rate? What's the perfect use failure rate? What population was it studied in? How good's the quality of the evidence? Is the claim from an industry study or independent research? Dig in around these methods because the information is flying at you around these methods from lots of different sources, not all of them are liable. Know that the rhythm is not the same as every other FABM out there. Consider your circumstances if you're somebody considering using these methods. How important is it that you don't get pregnant right now? Would you want an abortion if this method or any other contraceptive method failed? And what would abortion access look like for you right now if you are living in a place such as the United States where access may be patchwork or for individual people may be untenable? Can you and your partner navigate using a method like this together? I think it is a really important question for people. If you already are using an FABM, make sure you're using it correctly and consistently. And if you're using a technology-supported approach to FABMs, really be sure that you're using a device that's cleared by a regulator specifically for contraceptive use. It is hard for consumers to know when this is the case, but we're trying to put as much information out there to help people understand more clearly. And similarly, watch out for the red flags on social media, the fear-based messaging that other methods are kind of always dangerous with no nuance about what the epidemiological data actually show. Or try to understand when you're getting information from influencers who maybe subtly or openly benefit financially from selling FABM-related products or books or courses. There's a lot of this kind of thing happening out there. And I think people should be thoughtful about the financial flows of how some information is presented to us. I think I've already mentioned, for providers, consider getting familiar with these methods and think about the ways in which you're responding to folks who might be interested in them. Have the nuanced conversation to the greatest extent possible within your incredibly limited clinical minutes. And I guess finally I would say to folks in our field, researchers, advocates, everybody, it's time to take these methods, FABMs and FemTechs, seriously. They are part of the full spectrum of care. We need to fund research, we need to push for better regulation, we need to train providers, we need to combat misinformation. There's a lot we need to do, but we need to never lose sight of the fact that expanding FABM access only matters if we're simultaneously protecting and expanding access to everything else that is part of sexual and reproductive health care, other contraceptive methods, abortion, IVF when needed, comprehensive sex education, as you've mentioned, and support for families in need. The goal here isn't to get everybody to use the same method, it's to ensure that everybody has the information, resources, and freedom to make the decision that's right for them.

Jennie: That's such a perfect end to make sure that everybody has the method that works for them. That's really what we have been focusing on, that just making sure you're finding what works for you and trying different ones to find the one that fits the way you want and the way you want to feel and it is successful and that that you can keep up.

Jennie: Absolutely. Chelsea, thank you so much for being here. It was so much fun to talk to you.

Jennie: Likewise, thank you for having me. It's an honor.

Jennie: Okay, y'all. I hope you enjoyed my conversation with Chelsea. I had a great time talking to her all about FABMs. I learned a lot and it was great. I really had a great time. So, I will see everybody next week.

Jennie: [music outro] If you have any questions, comments, or topics you would like us to cover, always feel free to shoot me an email. You can reach me at jennie@reprosfightback.com, or you can find us on social media. We're at rePROs Fight Back on Facebook and Twitter, or @reprosfb on Instagram. If you love our podcast and want to make sure more people find it, take the time to rate and review us on your favorite podcast platform, or if you want to make sure to support the podcast, you can also donate on our website at reprosfightback.com. Thanks all.