BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2018-200110 on 21 July 2018. Downloaded from Personal view Social media and advertising natural contraception to young women: the case for clarity and transparency with reference to the example of ‘Natural Cycles’

Amy Hough,1 Maggie Bryce,1 Simon Forrest2

1London School of Hygiene and If you are a young female in the UK that ‘perfect use’ figures in their marketing, Tropical Medicine, London, UK 2 uses social media (as 96% of 16–24-year- they do not mention that very few women Institute of Health and Society, 1 Newcastle University, Newcastle, olds do), you may have come across an achieved ‘perfect use’. UK advert for Natural Cycles since they began A 2012 Cochrane Review evaluating their media campaign in late 2016, when fertility awareness as a method of family Correspondence to using platforms such as Facebook, Insta- planning, stated that “the comparative effi- Amy Hough, London School of gram or Twitter. Natural Cycles is a ‘natural cacy of fertility awareness-based methods Hygiene and Tropical Medicine, London WC1E 7HT, UK; ​amy.​ contraception’ app that was created by a of contraception remains unknown […] hough1@student.​ ​lshtm.ac.​ ​uk Swedish particle physicist and her partner. contraceptive methods should be prop- For £39.99 per year, users log their body erly evaluated, preferably in randomized Received 20 March 2018 Revised 2 June 2018 temperature each morning, and occasion- controlled trials, before adoption and 4 Accepted 19 June 2018 ally other details, such as their menstru- dissemination”. Natural Cycles has never ation, and an algorithm determines their been evaluated in a randomised controlled fertile days (during which the user would trial, the evidence is drawn from the need to use barrier contraception or avoid prospective cohort study outlined above. sexual intercourse). It has been approved The Family Planning Association have as a medical device for contraceptive also called for more rigorous, indepen- purposes in Europe.2 dent research into fertility awareness

The most recent study of the app was based apps before they can be compared http://jfprhc.bmj.com/ funded and primarily run by Natural with other forms of contraception.5 Cycles. The study was a prospective obser- Despite this, under the ‘science’ tab of the vational study of 22 785 users who were Natural Cycles website, the makers of the mostly Swedish and had an average age of app invite comparisons between the app 29 (SD=5) years. They do not mention and the combined contraceptive pill/oral the previous contraceptive practices of contraceptives, the intrauterine device, 2 their population. Women were considered condoms, and natural family planning. on September 26, 2021 by guest. Protected copyright. pregnant if they reported it to the app, or Natural Cycles could also be more if the timing of when they stopped using consistent in providing information the app made it likely they were pregnant. around barrier contraception. They do With perfect use, Natural Cycles claims advise on their website and in commercial a failure rate of only 1.0 pregnancy per partnerships with social media influencers 100 woman-years. With typical use of that barrier methods do need to be used to the app, the failure rate increases from protect against sexually transmitted infec- © Author(s) (or their 1.0 to 6.8 pregnancies per 100 woman- tions; however, this is not mentioned in employer(s)) 2018. No years. However, less than 10% of the user every marketing campaign, for example, commercial re-use. See rights data qualified as ‘perfect use’ and contrib- a series of advertisements on Instagram and permissions. Published by BMJ. uted to the analysis. If they included all which emphasise that women are only women for which the pregnancy status fertile on up to 6 days of their menstrual To cite: Hough A, Bryce M, was unknown (who could possibly be cycle, but do not contain any advice about Forrest S. Published Online First: [please include Day pregnant) this went up to 9.0 pregnan- barrier methods. Month Year]. doi:10.1136/ cies per 100 woman-years.3 Although The approach adopted by Natural bmjsrh-2018-200110 they acknowledge both ‘typical use’ and Cycles exposes the relatively weak

Hough A, et al. 2018;0:1–3. doi:10.1136/bmjsrh-2018-200110 1 BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2018-200110 on 21 July 2018. Downloaded from Personal view regulatory environment around social media and the high discontinuation rate (54% at 12 months) and advertising of contraception to the dissemination of low proportion of women contributing to the perfect partial information to potentially naïve and suggest- use analysis (less than 10%).3 ible audiences. Currently, the UK Code of British Under the circumstances, we consider it is Advertising requires all advertisements for broadcast important that Natural Cycles’ marketing materials media (television and radio) to go through a specific, ought to be entirely transparent, more clear than rigorous clearance process. There are 34 rules specifi- they currently are about the limitations of their app cally for medical devices and treatments, including not and pregnancy risks, and consistent across the board allowing well-known people to present the product.6 about barrier advice, so as to enable women to make This stringent regulation does not apply to marketing a fully informed choice. We also call for Natural on social media, which is self-regulated, and it is up to Cycles to stop using social media influencers with social media users to report to the Advertising Stan- followings comprising women aged under 18 years, dards Authority content they think is incorrect or inap- or whose primary audience falls outside the age propriate. In the UK, it is not permitted to advertise bracket or lifestyle of the women whose data formed prescription-only medication, which applies to most the basis of their research. pharmaceutical contraceptives.7 The example of Natural Cycles draws attention It seems problematic therefore that advertising of an to a wide range of problems and potential prob- app like Natural Cycles is allowed, where it is not in lems with commercial use of social media to market relation to a number of more mainstream and better- contraception including not only this use of ‘influ- tested contraceptive products and methods, with all encers’ and how information about reliability and that entails in terms of the public availability of infor- effectiveness is reported, but also the need for more mation on the topic. research to understand social media impact and Natural Cycles heavily market their app using how content is understood. According to business targeted advertisements on social media. In comparison magazine Campaign, who awarded Natural Cycles to other population groups, young women who are its ‘Pick of the Month’, “50% of subscriber growth regular social media users are most likely to trust social [was] attributable to marketing efforts on Facebook media content.7 Personal information such as search and Instagram”.10 Natural Cycles have understand- interests and political views are mined by advertisers ably and effectively taken advantage of a less-regu- 8 to build up this relationship with their audience. This lated arena with few competitors, which may lead trust may be even stronger when it appears to originate some to question the adequacy of the regulation of from a person they can relate to rather than a brand. social media and its role in advertising. For women By engaging well-known social media stars with large that want to use natural methods and understand followings (social media influencers) to promote their their reproductive cycle, this app offers an oppor- product, companies exploit the trust that individuals tunity for empowerment and possibly the most hold for people they admire online. Often influencers effective method of fertility awareness tracking for http://jfprhc.bmj.com/ describe their transition from hormonal contraception contraceptive purposes, but commercial impera- to Natural Cycles and provide followers with a link to tives have arguably got in the way. Natural Cycles a discount code. One caption describes switching to has the opportunity to stake a claim as the leading Natural Cycles from “putting hormones in my body” commercial operator in this field, but to do so it as “probably best decision this year” and being “already must ensure that it provides absolutely full and happier”. According to their website, within their large frank information about the efficacy and limitations marketing department they have two employees with of its products. on September 26, 2021 by guest. Protected copyright. the job title ‘influencer manager’.9 One of the influ- encers they have chosen is a star of a reality television Contributors AH and MB conceived the idea, all authors show that is very popular with young teenagers and so contributed to writing the article. it is likely a proportion of their following is comprised Competing interests None declared. of people under the age of 18 years, despite the age Patient consent Not required. restrictions of the product (which are easy to bypass). Provenance and peer review Not commissioned; externally One of the most popular YouTube videos posted by peer reviewed. another 22-year-old influencer, with three million YouTube subscribers, shows how to create four ‘back References to school’ hairstyles, implying that her audience is also 1 Prescott C. Internet access – households and individuals: 2017. younger teenagers. Users are then described as ‘cyclers’ London: Office for National Statistics, 2017. in the app and in promotional material, which creates 2 Natural Cycles. Science is our thing. 2018 https://www.​ a pack mentality similar to the One Direction fans - naturalcycles.com/​ ​en/​science (accessed 3 Mar 2018). ‘directioners’, and Justin Bieber fans - ‘beliebers’. 3 Berglund Scherwitzl E, Lundberg O, Kopp Kallner H, et al. Using the app correctly is time consuming and Perfect-use and typical-use Pearl Index of a contraceptive requires heavy user involvement, possibly explaining mobile app. Contraception 2017;96:420–5.

2 Hough A, et al. 2018;0:1–3. doi:10.1136/bmjsrh-2018-200110 BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2018-200110 on 21 July 2018. Downloaded from Personal view

4 Grimes DA, Gallo MF, Grigorieva V, et al. Fertility awareness- https://www.​asa.org.​ ​uk/​uploads/​assets/​uploaded/​cacc4b1f-​ based methods for contraception. Cochrane Database Syst Rev 5171-​4ba4-​8679bb383a25aa2a.​pdf (accessed 26 May 2018). 2004 4:CD004860. 8 Warner-Søderholm G, Bertsch A, Sawe E, et al. Who trusts 5 Family Planning Association. Sexual and reproductive health social media? Comput Human Behav 2018;81:303–15. experts call for more independent research on fertility apps. 9 Natural Cycles. Marketing. 2018 https://career​ .​naturalcycles.​ 2017 https://www.​fpa.​org.​uk/news/​ ​sexual-and-​ ​reproductive-​ com/​departments/​marketing (accessed 3 Mar 2018). health-​experts-​call-more-​ ​independent-​research-​fertility-​apps 10 Simpson G. Naturally creative – how Natural Cycles’ (accessed 3 Mar 2018). marketing campaign achieved a massive uplift in brand 6 Advertising Standards Authority. The UK Code of Broadcast awareness. Campaign. 2018 https://www.​campaignlive.co.​ ​uk/​ Advertising [Internet]. https://www.​asa.org.​ ​uk/​uploads/​ article/naturally​ -​creative-​natural-​cycles-​marketing-​campaign-​ assets/​uploaded/​d34f6bcf-​d281-​4eba-​bcf0fa76297f5779.​pdf achieved-​massive-​uplift-​brand-​awareness/​1485230 (accessed 26 (accessed 9 Mar 2018). May 2018). 7 Advertising Standards Authority. The UK Code of Non- broadcast Advertising and Direct & Promotional Marketing. http://jfprhc.bmj.com/ on September 26, 2021 by guest. Protected copyright.

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