A Mixed-Methods Assessment of Health Care Providers' Knowledge, Attitudes, and Practices Around Fertility Awareness-Based Methods in Title X Clinics in the United States

Objective: To understand how Title X providers currently engage with fertility awareness-based methods (FABMs) for pregnancy prevention in Title X clinics across the United States. Materials and Methods: We developed a survey to assess knowledge of fertility for purposes of pregnancy prevention, attitudes toward FABMs use for pregnancy prevention, and practices when patients request FABMs for pregnancy prevention. Results: In total, 329 participants who met all inclusion criteria completed the survey. Respondents were generally highly knowledgeable on fertility, felt neutrally toward FABMs or thought they were a nonviable option for most women, and were likely to respond to patient requests for FABMs for pregnancy prevention by providing information. Qualitative responses included several barriers to provision of FABMs for pregnancy prevention and few successes to provision. Conclusions: Fertility knowledge and discussion of specific methods increased with the number of methods included in the clinic's written materials or with the number of different FABMs someone at that clinic had been trained on. Significant clinician or administrative barriers may exist to offering FABMs to patients. Incorporating up-to-date information on a range of FABMs—rather than treating them as one method—into contraceptive counseling represents an opportunity to increase the contraceptive offering for clients who want them, leading to increased patient satisfaction and successful family planning outcomes.


Introduction
Fertility awareness-based methods (FABMs) of family planning rely on women interpreting their individual physiological signs, such as the timing of the menstrual cycle, changes in cervical fluid, basal body temperature, and/or increases in urinary hormones to predict current fecundity. The underlying contraceptive principle of FABMs is that people can reduce their chance of pregnancy by abstaining from vaginal intercourse or using an alternative method of contraception during days of potential fecundity.
There are many different FABMs, each relying on different method rules and one or more physiological signs. 1 For example, the Standard Days method relies only on menstrual cycle timing, and women consider themselves fertile between days 8 and 19, whereas symptothermal methods utilize signs such as cervical fluid and basal body temperature in combination to identify fertile days. A recent systematic review found moderate quality typical use pregnancy estimates for 12 specific FABMs ranging from 2% to 33% per 100 woman/years. 1 FABMs are the preferred method of use for a small but growing number of contraceptive users of FABMs in the United States. 2 The Office of Population Affairs reported an increase in the number of female family planning users whose primary method of contraception is FABMs from 8784 in 2007 to 15,287 in 2017. 3,4 People who use these methods may desire to avoid hormones, adhere to religious teachings, involve the male partner in reproductive decision making, and/or feel more in tune to the functioning of their reproductive system. Besides contraceptive uses, FABMs may also be used by women or couples to achieve a pregnancy or monitor health conditions, such as polycystic ovary syndrome and infertility. 5 In turn, they must accept that these methods may be less effective than some other methods and are especially susceptible to imperfect use. People who use FABMs deserve transparent information about their effectiveness, benefits, and challenges.
Recently, the Office of Population Affairs, which administers the Title X grant program, identified FABMs as a key topic for the Title X network, with requirements for Title X providers to offer counseling on these methods as part of offering a broad range of contraceptive methods. Despite increasing demand and federal attention, little is known about current provider knowledge, attitudes, and practices related to FABM counseling and provision, 6,7 and nothing is known about these aspects specific to Title X providers. The purpose of this study was to understand how Title X providers currently engage with FABMs for pregnancy prevention in Title X clinics across the United States.

Materials and Methods
To assess provider knowledge, attitudes, and practices related to FABMs for pregnancy prevention, we developed a survey for Title X-funded clinic staff across the United States.

Participants
We posted a link to the survey on the Title X National Clinical Training Center for Family Planning website and additional survey links in newsletters from the Title X Family Planning National Training Center, the Office of Population Affairs, and the National Family Planning and Reproductive Health Association.
It was also sent directly to e-mail addresses on file for providers at Title X clinics.
Responses were included in this analysis if respondents affirmed that their primary clinic setting provided family planning services and received federal Title X family planning funds and that they held a clinical role in that setting (nurse, provider, etc.). Responses from manager/administrators or billing/ finance staff were excluded from this analysis, which was focused on understanding FABM knowledge, attitudes, and practices among providers of contraception and/or contraceptive counseling.

Instruments
The survey instrument consisted of a 53-item survey created by the authors and tested by three FABM subject matter experts. Both the terms ''FABMs'' and ''NFP'' (natural family planning) were defined in the survey to ensure respondents understood that ''FABMs'' included all fertility tracking methods. Survey items included multiple choice, true/false, yes/no options, Likerttype, and open text questions. The survey questionnaire is provided in Appendix A1.
Knowledge. We assessed knowledge of fertility for purposes of pregnancy prevention with four true/false ''knowledge'' questions. These questions included identification of the normal menstrual cycle length, characteristics of cervical mucus around the time of ovulation, normal basal body temperature increase after ovulation, and length of the luteal phase.
Attitudes. To assess provider attitudes toward FABM use for pregnancy prevention, we asked the participants to rate the viability of FABMs as a method of contraception on a Likert scale, with 1 being ''a nonviable option for most women,'' 3 being ''neutral,'' and 5 being ''a viable option for most women.'' Practices. To assess provider behaviors, we asked participants to describe how they responded to patients requesting an FABM for pregnancy prevention. In addition, we asked two open-text questions querying providers about existing barriers to providing FABMs, as well as their experiences of success in providing these methods for pregnancy prevention.

Data collection
The survey was hosted by REDCap 8 and contained a consent script that explained the purpose of the study and ensured participation was anonymous and voluntary. The survey was open for 11 weeks. This study was approved as exempt with a waiver of signed informed consent by the University of Missouri-Kansas City Institutional Review Board.

Data analysis
For quantitative responses, we conducted descriptive analyses for comparative outcomes. In addition, we conducted multivariable logistic regression analyses to assess the associations between the number of FABMs respondents clinics' have training on or offer materials for and respondents' knowledge, attitudes, and practices toward FABMs. All quantitative analyses were conducted using SAS version 9.4 (SAS Institute, Cary, NC). 9 For open text, short-answer responses on questions about provider successes, and barriers to FABM provision, we conducted emergent thematic coding to identify existing themes and subthemes associated with each question. In addition, we conducted textual analyses on extension questions (e.g., ''other, please specify'') and quantitatively grouped these responses in new or existing answer categories.

Results
An invitation to complete the survey was sent to 8002 e-mail addresses of family planning providers and was also placed on national websites as already detailed. A total of 458 family planning providers completed the anonymous online survey. This represents a 5.7% response rate of e-mailed invitations; however, with the inclusion of those who may have come across the survey on national websites, which is not possible to calculate, the response rate is likely much lower. The current sample includes 329 participants (71.8%) who met all inclusion criteria.
Of those completing the survey, 97.0% of respondents identified as female and almost half (45.0%) identified as clinical providers (NP, CNM, PA, MD, and DO), whereas another 48.0% identified as nurses. Among respondents who reported nursing licensure, the largest subspecialty were registered nurses (42.6%). Providers reported a variety of practice settings, including health departments (72.6%), community/federally qualified health centers (13.1%), and free-standing family planning organizations (8.5%) ( Table 1).

Knowledge
A majority of participants answered all of the fertility questions correctly (52.0%). More than 90.0% of respon-dents could correctly identify both luteal phase length (91.2%) and characteristics of ovulatory cervical fluid (94.2%). Participants were less likely to know the typical length of the menstrual cycle (80.2%), or about the shift of basal body temperature after ovulation (74.5%). Our multivariable regression model identified associations between the number of correct answers a participant reported and the reported number of different FABMs included in written information provided to patients (b = 0.192, p < 0.05) and by the number of FABMs that they reported formal training on (b = 0.195, p < 0.05) ( Table 2).
This response was not significantly impacted by the number of FABMs included in the written information provided to patients (b = 0.012, p = 0.778) or by the number of FABMs that those at the participant's facility have been formally trained on (b = 0.085, p = 0.087), although this number approaches significance.  Qualitative responses Barriers to providing FABMs as a contraceptive option. The most commonly reported barrier (n = 77) was provider perceptions that these methods were inappropriate for their clients. Other barriers to FABMs for pregnancy prevention included perceptions that clients did not desire to use FABMs, that clients could not afford the supplies required to use an FABM, and that FABMs themselves are less effective methods of contraception compared with other methods (Table 4).
Many providers identified that they and their clinical staff did not have the training to counsel on these methods. They also noted the lack of available educational materials to give to women interested in learning about FABMs. Many spoke about the time-intensive nature of counseling on these methods and the struggle to fit this type of discussion into a 15-minute visit window. Others noted funding and administrative limitations to inclusion of these methods in counseling such as a lack of funder reimbursement for these meth-ods, or a lack of administrative support to develop educational materials or train staff on FABMs.
Successes in providing FABMs as a contraceptive option. The majority of providers did not report any successes in incorporating FABMs into their contraceptive counseling for pregnancy prevention. Those who had successes associated them with certain demographic groups of women who used them. Successes mentioned with incorporating FABMs in contraceptive counseling included successful use to avoid pregnancy in conjunction with barrier methods and/or mobile apps such as Cycle Beads (Standard Days method), improved body literacy and fertility knowledge, and good outcomes with high satisfaction among women who were ''self-motivated'' (Table 4).

Discussion
In our knowledge, this is the first study to assess provider attitudes, knowledge, and behaviors on FABMs  and frankly feel that this is a method best used by monogamous individuals and families seeking pregnancy rather than pregnancy prevention.'' Female provider, age 61-65 years, Missouri ''None! Title X is going to be worthless now. within the Title X network of providers in the United States. The low response rate should be noted and data treated as a preliminary study. The findings of this study may not represent the views of the entire Title X network of providers, especially as we think those who feel passionately about the topic (either positively or negatively) were more likely to respond than those who felt more neutral. It is also important to note that although FABMs are used widely internationally, this study is not representative of any global populations.
Although a majority of providers had correct general knowledge of fertility, few providers demonstrated positive attitudes about offering FABMs as a viable option for pregnancy prevention. Most reported neutral or negative perceptions about these methods, something that has been found in other studies, 10,11 coupled with a common perception of these methods as ''ineffective'' or inappropriate for their clients. This finding is similar to that found in previous studies in non-Title X providers, where a majority of clinicians underestimate the effectiveness of FABMs and do not always provide all information about modern FABMs. 6,7,10,11 We found preliminary evidence to suggest that providers who had written materials around multiple methods of FABMs were more likely to counsel clients around FABM use. This may be due to increased confidence among providers who had received resources to provide these methods or a better understanding of FABM effectiveness data, but it could also be that providers who were more likely to counsel about FABM use were also more likely to have written materials about their use.
Our qualitative analyses identified significant provider barriers related to offering FABMs as a viable option for specific client populations, including those with low health literacy, individuals who are single parenting, young people, and those who are facing challenging life circumstances. Patients with low health literacy may incorrectly identify their fertile window, 12 which is an opportunity for reproductive education interventions. FABMs cannot be used effectively and should not be recommended in a relationship in which timing of intercourse cannot be mutually decided upon and/or a barrier method cannot be used. For women who have unique reproductive considerations (e.g., long cycles, anovulation, and breastfeeding), there is limited data about FABM effectiveness. However, even in some of these cases, an FABM may be the only method that a person would con-sider, for example, if they have a religious consideration. Therefore, even these groups deserve to have a reliable source of information about FABMs. Perhaps more importantly, FABMs have been used with typical use pregnancy rates similar to those for hormonal methods and barrier methods in several populations that were a point of concern among participants, including low-literacy populations [13][14][15][16][17][18][19][20] and young single women with multiple partners. [21][22][23][24] One small study in the midwest indicated that when women were educated about FABMs, more were interested in using them. 6 Therefore, some of these provider barriers may reflect misperceptions of the effectiveness of FABMs that could be addressed through increased education and training, as well as improved clinic materials. FABM education for clinicians or patients should stress the differences between the many modern methods. There are methods available that are designed to be simple and easy to use with little or no equipment or supplies needed, some are complex and require some equipment, supplies, or technology, and all methods differ in their effectiveness of pregnancy prevention. 1 Some methods are not suitable for women with irregular menstrual cycles and some women may have preferences on the symptoms they check. All these aspects of the different FABMs should be taken into consideration when providing contraceptive counseling to a patient who is interested in FABMs. In addition, the differences between methods may dispel some beliefs that patients or providers have about FABMs if they view them as a whole, such as the belief that they are not effective or the belief that they require too much equipment.
Clinicians reported providing verbal and written information to clients who requested FABMs; however, few clinics reported having training or education around FABMs onsite. Other studies have shown that medical students or residents are unlikely to include FABMs in curriculum or learning experiences. 5,25,26 Several providers noted a lack of time for FABM counseling within existing clinical schedules. This barrier mirrors a similar reported time barrier for other contraceptive services, including same-day insertions of intrauterine devices or vasectomy, 27 and methods such as Standard Days Method can be provided within the typical visit time frame, particularly if written materials are also available. Opportunities for improvement may include the development of FABM clinical trainings as CME-approved offerings, as providers are more engaged in learning new methods when they support their licensure requirements. In addition, the development of comprehensive written materials that provide an overview of multiple methods may improve both provider self-efficacy and increase clinical knowledge. Recent studies have found that provider method bias is common, 28,29 but additional training on contraceptive shared decision making may be an opportunity to reduce bias against certain methods, such as FABMs. 30 Table 5 includes some links to training and resources for clinicians on FABMs.
Additional research is needed to better understand the acceptability of FABMs as contraception for both providers and patients and determine best practices in offering and counseling on FABMs in a family planning visit. Assessing the success of clinical interventions to improve scheduling availability for same-day services that include FABMs would provide valuable insight into how these methods can be practically incorporated into the clinic offering. Other important areas of future study include demonstrating whether broader understanding of fertility information may be helpful in health decision making and assessing whether emerging digital fertility applications lead to increased options for those who desire to use FABMs.
Patient satisfaction and successful family planning outcomes have been directly tied to increased availability of the full range of contraceptive methods. 31 Incorporating FABMs into contraceptive counseling represents an opportunity to increase the contraceptive offering for clients who want them. Despite existing barriers to clinical provision, increasing demand for these methods, as well as recent federal interest in their availability, could support the development of new strategies to incorporate FABMs more fully into contraceptive counseling.