Natural Cycles & The Reality Of Digital Contraception

Looking at the list of contraception available to women in the UK, it seems like there are loads of choices. Several varieties of both the single hormone or dual hormone pill, the patch, the injection, the hormonal or non-hormonal coil, the implant, male or female condoms, the diaphragm. But should you have migraines, or experience side-effects from hormonal contraceptive use, have a latex allergy, be reluctant or unable to go through an uncomfortable (at best) copper coil insertion, the list gets a lot shorter very quickly. This is where contraceptive apps like Natural Cycles come in.

Natural Cycles promises women a high-tech means of preventing pregnancy that doesn't involve hormones, irritating condoms, or invasive procedures. It claims to use an algorithm based on daily temperature readings and other inputted data to help tell a woman when she's safe to have sex without protection (green days) and when she isn't (red days). It's the only app of its kind to be FDA-approved for use as contraception and was given the go-ahead by German authority Tüv Süd for use across the EU in 2017. As per the Natural Cycles website, the app claims to be 93% effective with standard use and 98% effective with perfect use, and it's rated 4.8 stars out of 5 on the Apple App store. It costs between £40 and £72 a year to use.

So far, so beguiling. Or at least it was until an article published in The Guardian in July last year sparked a backlash by reporting that a number of women had experienced unexpected pregnancies after using the app.

According to Natural Cycles' Facebook page, the app "all started with one woman," co-founder Dr. Elina Berglund, a particle physicist who was part of the team that discovered the Higgs boson. I spoke to Dr. Berglund about the impact of last year's backlash, why Natural Cycles continues to use controversial influencer marketing, and who its intended user really is.

In most heterosexual partnerships, contraception is still seen as the woman's responsibility. Trials of a male hormone-based contraceptive were memorably halted in 2016 when the men participating reported similar side effects to those women have been experiencing since the pill's creation. And per a recent study, funded by Natural Cycles, 65% of 25 to 34 year-old British women are using period tracker apps (where users are given information about their cycle based on data they input) as a method of contraception. If this is correct, the demand for alternatives to established forms of contraception is clear.

Berglund certainly believes that women need more choice. Per the Natural Cycles's Facebook page, it was the reason she created the app. Its reads: "Dr. Elina Berglund was looking for an effective, hormone-free method of birth control but none of the available options were right for her. So what did she do about it? Invented one that did work for her, that’s what." Berglund confirms this in her own words, saying: "I think women need to have easily accessible contraceptive methods that are effective and easy to use."

However, it's difficult to reconcile this wish with Natural Cycles' actuality. While the app does, in theory, enable women to use it as a contraceptive, it only does so on days when it has given them a green day. A red day means that it's not safe to have sex without other contraception. As Berglund notes: "The messier the data or the cycle, the more red days in general but the effectiveness stays the same." This means women who sometimes wake up with hangovers, have irregular sleep cycles, or simply forget to take their temperature as soon as they wake up (yes, that means before grabbing a glass of water or going to the loo) will be met with more red days.

Gynaecologist Dr. Anita Mitra, who writes under the name the Gynae Geek, shared her concerns about Natural Cycles in a blog post back in 2017. She wrote: "The app will work as contraception if it correctly calculates the day that you ovulate, and you either use a condom, or don’t have sex on the red days. I truly believe that it’s only really suitable as a contraceptive for women who would not be devastated if they did get pregnant."

When The Guardian spoke to Berglund's husband Raoul Scherwitzl, the other co-founder of Natural Cycles, in July 2018 about the issue around app users' unexpected pregnancies, he explained that the app's target user was actually women who were looking to get pregnant in the near future rather than those wishing to prevent pregnancy for the long term. Berglund told The Guardian earlier this year that experiencing this situation, in part, inspired the app's creation. The co-founders now have two children together.

Berglund tells me that, although Natural Cycles has "a strict requirement that the user has to be above 18 years old," the average age of users is actually around 30. "We know the typical user is a woman in a stable relationship [and] is considering maybe having children in a few years' time," Berglund explains.

In fact, Berglund cites the app's lack of effect on women's hormones as an upside because it may enable users to get pregnant more quickly after stopping using the app. "We've seen that our users really appreciate the fact that they can use the product both to prevent pregnancy and then also plan the pregnancy when the time is right. We see in our data that if you use Natural Cycles before you want to get pregnant [it] decreases time to pregnancy by 60% compared to if you use the pill before, because the woman then knows about her body, knows when she ovulates, and also the pill can sometimes delay [pregnancy]," Berglund explains.

Natural Cycles' use of influencer marketing was also criticised in the July 2018 Guardian article where it was reported that Instagram users received recommendations to try the product from bloggers they followed. I experienced this first hand when, in March 2018, I saw a post promoting the app from a fashion influencer I followed on Instagram at the time. I didn't, and still don't, fit the profile of Natural Cycle's professed target user, and yet I was targeted by their marketing.

So I'm surprised to hear that not only is Natural Cycles still using influencer marketing, but that they view it as a useful tool. "We do still use influencer marketing but we have a strict process on how to choose what influencer, what they need to say etc. In fact, we see influencer marketing as a way to do quite targeted marketing," Berglund tells me.

"The women are actually the most suitable for our product, compared to if you do like a TV commercial, then you reach all kinds of women. We do a background check — what is the average age of the reader, are they maybe in a relationship, and we also make sure that they always mention the effectiveness of Natural Cycles and that no contraception is 100% effective," she notes.

While marketing the app via influencers may make it easier to hone down targets, there are also less stringent rules around advertising through influencers than there are for more traditional methods, as legal news website Lexology notes. And the fact that influencer marketing is more targeted means wider conversations about the products featured are less likely to take place. It's hard to imagine there would have been such an uproar around Protein Worlds's notorious Beach Body Ready ads in 2015, for instance, had they not been on large posters and billboards in the London Underground.

I'd argue that some of Natural Cycles social media marketing remains questionable. For example, as per a recent Instagram post, they claim "the only side-effect of using Natural Cycles is getting to know your body." Reading this, I suppose you could say that an unintended pregnancy is a way of getting to know your body.

Natural Cycles has also been pulled up on misleading advertising in the past. In 2018, the UK's Advertising Standards Agency banned two paid for posts from the company, ruling that Natural Cycles must "not to state or imply that the app was a highly accurate method of contraception and to take care not to exaggerate the efficacy of the app in preventing pregnancies."

Influencer marketing operates a bit like a recommendation from a friend, which is problematic when it comes to something that is essentially a medical device. Take one recent sponsored post relating to Natural Cycles from an influencer with polycystic ovary syndrome, for example. It's not difficult to imagine how someone else with PCOS might see it and think, "if it works for her it might just work for me." Add to this the fact that, unlike other forms of contraception, you don't have to have a consultation with a medical professional before beginning to use Natural Cycles, it's easy to see how someone might switch to the contraception without ever discussing it with another person.

While those with PCOS can use the app, it's less useful due to the often irregular nature of their menstrual cycles. This is flagged in the post I saw, but not until the very bottom. When I ask Berglund about this she tells me: "It's not less effective for women for women with PCOS, however it may be less useable as a contraceptive method because if you have very irregular cycles like women with PCOS tend to have you end up getting quite a lot of red days. The effectiveness is the same but it will require quite a lot of condom usage."

One of the major headlines of The Guardian article that kickstarted the Natural Cycles backlash was the fact that, in January last year, "a major Swedish hospital reported that 37 of the 668 women who had sought an abortion there between September and December 2017 were using Natural Cycles as their sole birth control." This led to an investigation from the Swedish Medical Products Agency. As per Digital Health, the investigation cleared Natural Cycles, concluding that the number of pregnancies was in line with the app's claimed rate of effectiveness. Berglund says the result did not come as a surprise:

"Being a digital contraceptive method has the benefit of being on top of our data and real time tracking our pregnancy rates, because unfortunately, when when you do work with contraception, no contraception is 100% [effective]. There will always be unplanned pregnancies."

She continues: "As a digital contraception, we need to track and report on a monthly basis if the rate of unintended pregnancy is [in line] with the effectiveness. And this is also what we then reported to the Swedish Medical Products Agency. We never had any doubts in our product because we knew it performed as it should."

But despite her confidence, Berglund isn't unaffected by unplanned pregnancies which occur while using the app. "It was still a very tough time because it's always very tough for those individual women who do find themselves unintentionally pregnant. It is a big doubt about working in the space of contraception but innovation is very important. And we know that overall we do reduce unintended pregnancy," she explains.

But while this assertion may be factually correct, it's a very narrow truth. The app may reduce unintended pregnancy, but despite best efforts, it can’t cover a woman for every day of her cycle, it relies on a higher level of user discipline than remembering to take a tablet, which arguably make lapses more likely, and it isn't as useful for women with irregular cycles.

That takes me back to Natural Cycles' Facebook description, where it says the app was essentially designed for Berglund. I think this is some of the app's most accurate marketing material. Berglund has succeeded in creating an app for herself — a high-achieving white woman in her 30s, in a stable relationship, who was looking to get pregnant in the near future — and women in similar circumstances. But for women who don’t find themselves in a position to manage an unwanted pregnancy, the app is probably not the best choice. As Dr Mitra wrote: "I certainly don’t criticise anyone who does want to use these apps as their contraception, but I do believe in helping people making informed decisions. Personally, for me it would not be reliable because I work nights, am frequently stressed and have terrible sleep hygiene." The question is whether the app’s top line marketing material makes that clear enough. As someone who was a recipient of their influencer marketing, I would argue not.

In a statement Berglund issued to Bustle, she added: “I created Natural Cycles with the belief that ANY woman — regardless of race, age, educational background — could benefit from having the ability to choose a non-hormonal birth control option in the form of Digital Birth Control. Birth control is not one fits all and choice is very important. This is something myself and my team passionately believe in and we are proud to have many diverse Natural Cycles members around the world who believe every woman should have the right to choose what works for them and their body.”

Natural Cycles isn't the only app of this kind, another contraceptive app called Dot is hot on its heels with similarly reassuring-sounding stats about effectiveness. That the fem-tech business is booming is clear, but whether it really has women's best interests at heart is less so.

Update: This piece has been updated to include comment from Natural Cycles. A previous version of this piece misstated current medical standards about women’s cycles. This has been updated. Further updates have also been made to clarify the article's position.