Haile, L. T., Fultz, H. M., Simmons, R. G., & Shelus, V. (2018). Market-testing a smartphone application for family planning: assessing potential of the CycleBeads app in seven countries through digital monitoring. mHealth. https://doi.org/10.21037/mhealth.2018.06.07
Haile LT, Fultz HM, Simmons RG, Shelus V. Market-testing a smartphone application for family planning: assessing potential of the CycleBeads app in seven countries through digital monitoring. mHealth. 2018. doi:10.21037/mhealth.2018.06.07
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CycleBeads fertility app drew 356,520 downloads in seven countries
Facebook ads aimed at Android users produced 356,520 CycleBeads app downloads in seven countries within 10 months. The app is a digital Standard Days Method tool. A market test published in 2018 reports a cost per download of $0.17 to $0.69 across countries. In-app surveys of self-selected users showed about 4 out of 10 used it to prevent pregnancy.
Key Findings
The app was downloaded 356,520 times within 10 months of advertising. Nigeria led with 110,582 downloads and Rwanda trailed with 2,061.
Advertisers paid the least per download in Nigeria at $0.17 and the most in Rwanda at $0.69.
Users gave three reasons for opening the app: 39.9% wanted to prevent pregnancy, 38.5% wanted to plan one, and 21.6% wanted to track their cycles.
Among users preventing pregnancy, the share with no family planning method in the 3 months before download ran from 46.2% in Egypt to 74.0% in Rwanda.
In all seven countries, approximately 60% or more of respondents said they would definitely recommend the app to a friend after cycle 3.
Interpretation
The authors ran a market test: a brief advertising campaign plus optional pop-up surveys inside the app. The results describe self-selected people who downloaded a free app and chose to answer. All data were self-reported, the surveys were not asked in the Hindi version, and response rates fell over time. The design did not assess changes over time, and each survey asked different questions. Women planning a pregnancy were left out of the survey analysis. The authors read the high share of users with no prior method as a sign that the app may reach women with unmet need.
RRM Context
The Standard Days Method is a fertility awareness-based method. It works from period start dates and fits women whose cycles run 26 to 32 days. The paper cites a 2016 review in which CycleBeads was one of six apps out of 30 that gave accurate fertility information. Cycles outside that range and technical problems were the main reasons women stopped using the app to prevent pregnancy. The authors name partner communication as a topic for future studies.
Our editorial summary of this paper, not the article's abstract.
Abstract
Background
The advent of new technological approaches to family planning has the potential to address unmet need in low- and middle-income countries. Provision of fertility awareness-based apps have the ability to provide accessible, direct-to-user fertility information to help women achieve their reproductive goals. The CycleBeads app, a digital platform for the Standard Days Method (SDM), a modern method of family planning, helps women achieve or prevent pregnancy, or track their cycles using the only their period start dates.
Methods
Brief social marketing campaigns were launched by the app developer to monitor cost and distribution of the CycleBeads app, understand the user profile, and assess user experience. Monitoring and evaluation through in-app micro surveys occurred over a 6-cycle period in seven countries: Egypt, Ghana, India, Jordan, Kenya, Nigeria, and Rwanda. In-app micro-surveys were utilized to collect data around demographics, mode of use of the app, prior experiences with family planning, and satisfaction to better understand women's interactions with the apps, and the possibility for meeting unmet need. Analyzes focused on women who were using the app to prevent pregnancy or track their cycles.
Results
Social media campaigns proved to be an easy, low-cost approach to advertising the CycleBeads app. As a result, 356,520 women downloaded the app, and the cost to the advertiser per download ranged from $0.17-0.69. A majority of app users were between 20-29 years old, married or in exclusive relationships. Overall, 39.9% of users were using the app to prevent pregnancy, 38.5% to plan a pregnancy, and 21.6% were tracking their cycles. Among the users preventing pregnancy, 64.1% of women had not used a family planning method 3 months before downloading the CycleBeads app. One-third of users who were using the app to track their cycles, reported that they had not been using any form of family planning. In all seven countries, nearly 60% of women reported that they would definitely recommend the CycleBeads app to a friend, indicating their satisfaction with the app.
Conclusions
Our main findings indicate that a social media campaign is a low-cost approach to making the CycleBeads app accessible to women. The app addresses multiple reproductive intentions and attracts a diverse demographic of users across different life stages. For many women the app was the first modern method they used in the last 3 months, showing that fertility awareness-based apps have the potential to address an unmet need. Future studies should focus on changes in behavior during the fertile window, partner communication, and future family planning intentions.
To characterize how commercially available fertility-tracking devices and wearables define ovulation and anovulation, evaluate available comparator evidence, and assess user burden across 19 selected technologies.
We conducted a structured landscape analysis of 19 fertility-tracking devices and wearables available in the United States. Technologies were evaluated for biomarker type, operational definitions of ovulation and anovulation, comparator evidence, intended use, regulatory status, and user burden, among other variables.
Technologies clustered into four major categories: luteinizing hormone (LH)-only devices, multi-hormone devices, basal body temperature (BBT)-based wearables, and BBT-based thermometers. LH-only devices generally defined ovulation by detecting an LH surge or peak; multi-hormone devices incorporated LH and/or pregnanediol-3-glucuronide (PdG) measurements; and BBT-based technologies relied on thermal shifts. Explicit definitions of anovulation were uncommon and were frequently inferred from the absence of ovulation-associated biomarkers. The existence and design of comparator evidence varied substantially across technologies. Most comparator studies relied on surrogate measures such as urinary or serum hormones, whereas few technologies had comparator evidence against physiological reference standards such as transvaginal ultrasound (TVUS). Comparator studies in irregular-cycle populations were uncommon despite frequent marketing of these devices as appropriate for users with irregular cycles. User burden varied substantially across technologies.
Fertility-tracking technologies demonstrate substantial heterogeneity in operational definitions, comparator evidence, and user burden. Greater transparency regarding ovulation and anovulation definitions, clearer reporting of comparator evidence, and more representative evaluation in irregular-cycle populations are needed to support accurate interpretation and integration into reproductive healthcare.
To identify factors associated with unacceptable Patient Acceptable Symptom State (PASS) responses, Visual Analog Scale (VAS) scores, and satisfaction at time of intrauterine device (IUD) placement.
Recruitment occurred at six Utah clinics between 6/24-2/25. Participants completed procedure surveys on demographics, reproductive history, anticipated pain, anxiety, and coping skills. Post-placement surveys assessed PASS responses, experienced pain by VAS (1-100mm) and satisfaction with IUD placement (5-point Likert scale). We determined factors associated with unacceptable PASS responses and a cut point delineating "low" vs "high" pain to assess measure associations.
Of 194 participants, 21% (n = 41) reported an unacceptable PASS, which was associated with higher mean anticipated (65 mm vs 51 mm; padj=0.01) and experienced (76 mm vs 46 mm; padj<0.001) pain, prior sexual assault (55% vs 28%; padj=0.016), or violent death of someone close (25% vs 7%; padj=0.024). In controlled analysis, higher experienced pain predicted unacceptable PASS (OR:1.10;95%CI:1.06, 1.14). "High" pain (≥61mm) occurred in 44% of all participants. Of those with high pain, 55% reported an acceptable PASS response. History of prior pelvic exam (p = 0.02, padj 0.20), prior IUD placement (p = 0.003; padj 0.12), or violent death of someone close (p = 0.011; padj 0.13) influenced unacceptable PASS responses in this group. Of all participants, 21% reported dissatisfaction (n = 16) or neutral response (n = 24) regarding their IUD placement, among which only 13 reported an unacceptable PASS (32%). Satisfaction was influenced by mean VAS score (61 mm dissatisfied/neutral vs 50 mm satisfied; p = 0.01; padj 0.90).
IUD placement pain level may influence satisfaction, but less than half of those with high pain (≥61mm) reported an unacceptable experience.
IUD placement pain experiences are multi-dimensional and cannot be described by pain level alone. High levels of placement pain influence satisfaction and overlap but are not collinear with acceptability responses. Acceptability of IUD may be subject to temporal bias and influenced by whether their goals/needs are met and whether the pain was ultimately worth it.
Nantume A et al., 2025·Drug and alcohol dependence·Free full text on PubMed Central
Substance use disorder (SUD) during pregnancy is associated with an increased risk of adverse maternal and neonatal outcomes, yet many patients face significant barriers to accessing treatment, including experiencing bias and stigma from healthcare providers. To inform improvements in care delivery, this study explored the experiences of healthcare providers who care for pregnant individuals with SUD.
Researchers conducted seven focus group discussions (FGD) and fifteen in-depth interviews (IDI) using semi-structured guides, with participants drawn from both rural and urban hospital settings across Utah. All discussions were audio recorded, transcribed verbatim, and examined using the Template Analysis approach.
Among FGD participants (n = 37), the sample was predominantly white (94.6 %), female (86.5 %), rural (89.2 %), and comprised of nurses (78.4 %). The IDI sample (n = 15) was more gender diverse (60 % female), had greater representation of physicians (53.3 %), and a higher proportion of urban participants (60.0 %). Template analysis revealed four major themes. First, providers held a range of perceptions toward pregnant individuals with SUD, reflecting both stigma and empathy. Second, many emphasized the importance of building trust through nonjudgmental communication and emotional support. Third, providers reported high levels of burnout, particularly due to limited resources and systemic barriers. Finally, participants highlighted knowledge gaps related to SUD clinical care and confusion around regulatory requirements like mandatory reporting.
Despite the challenges described, many providers expressed strong dedication to delivering compassionate, person-centered care. The findings underscore the need for targeted provider education, institutional policies that reduce care barriers, and increased community and institutional resources to better support patients with SUD during pregnancy.
Stanford JB et al., 2024·Linacre Q·Free full text on PubMed Central
Fertility awareness-based methods (FABMs), also known as natural family planning (NFP), enable couples to identify the days of the menstrual cycle when intercourse may result in pregnancy ("fertile days"), and to avoid intercourse on fertile days if they wish to avoid pregnancy. Thus, these methods are fully dependent on user behavior for effectiveness to avoid pregnancy. For couples and clinicians considering the use of an FABM, one important metric to consider is the highest expected effectiveness (lowest possible pregnancy rate) during the correct use of the method to avoid pregnancy. To assess this, most studies of FABMs have reported a method-related pregnancy rate (a cumulative proportion), which is calculated based on all cycles (or months) in the study. In contrast, the correct use to avoid pregnancy rate (also a cumulative proportion) has the denominator of cycles with the correct use of the FABM to avoid pregnancy. The relationship between these measures has not been evaluated quantitatively. We conducted a series of simulations demonstrating that the method-related pregnancy rate is artificially decreased in direct proportion to the proportion of cycles with intermediate use (any use other than correct use to avoid or targeted use to conceive), which also increases the total pregnancy rate. Thus, as the total pregnancy rate rises (related to intermediate use), the method-related pregnancy rate falls artificially while the correct use pregnancy rate remains constant. For practical application, we propose the core elements needed to assess correct use cycles in FABM studies.
Fertility awareness-based methods (FABMs) can be used by couples to avoid pregnancy, by avoiding intercourse on fertile days. Users want to know what the highest effectiveness (lowest pregnancy rate) would be if they use an FABM correctly and consistently to avoid pregnancy. In this simulation study, we compare two different measures: (1) the method-related pregnancy rate; and (2) the correct use pregnancy rate. We show that the method-related pregnancy rate is biased too low if some users in the study are not using the method consistently to avoid pregnancy, while the correct use pregnancy rate obtains an accurate estimate. SHORT In FABM studies, the method-related pregnancy rate is biased too low, but the correct use pregnancy rate is unbiased.
Symul L et al., 2019·NPJ Digit Med·Free full text on PubMed Central
For most women of reproductive age, assessing menstrual health and fertility typically involves regular visits to a gynecologist or another clinician. While these evaluations provide critical information on an individual's reproductive health status, they typically rely on memory-based self-reports, and the results are rarely, if ever, assessed at the population level. In recent years, mobile apps for menstrual tracking have become very popular, allowing us to evaluate the reliability and tracking frequency of millions of self-observations, thereby providing an unparalleled view, both in detail and scale, on menstrual health and its evolution for large populations. In particular, the primary aim of this study was to describe the tracking behavior of the app users and their overall observation patterns in an effort to understand if they were consistent with previous small-scale medical studies. The secondary aim was to investigate whether their precision allowed the detection and estimation of ovulation timing, which is critical for reproductive and menstrual health. Retrospective self-observation data were acquired from two mobile apps dedicated to the application of the sympto-thermal fertility awareness method, resulting in a dataset of more than 30 million days of observations from over 2.7 million cycles for two hundred thousand users. The analysis of the data showed that up to 40% of the cycles in which users were seeking pregnancy had recordings every single day. With a modeling approach using Hidden Markov Models to describe the collected data and estimate ovulation timing, it was found that follicular phases average duration and range were larger than previously reported, with only 24% of ovulations occurring at cycle days 14 to 15, while the luteal phase duration and range were in line with previous reports, although short luteal phases (10 days or less) were more frequently observed (in up to 20% of cycles). The digital epidemiology approach presented here can help to lead to a better understanding of menstrual health and its connection to women's health overall, which has historically been severely understudied.
Starling MS et al., 2018·mHealth·Free full text on PubMed Central
The rapid proliferation of fertility apps has created a market that has the potential to address the needs of women and couples worldwide. Some women who seek to prevent pregnancy are making behavioral decisions based on information they receive from fertility apps, yet fertility apps may not always be accurate and reliance on them could lead to unintended pregnancies. Little research has been done to understand who uses fertility apps for pregnancy prevention, how those who use them perceive their efficacy, and their preferences for how apps should be designed and presented to accurately assist them in preventing pregnancy.
A web-based pilot survey was launched through Facebook recruiting women who either currently use a fertility app for pregnancy prevention or intend to use one in the future. Data collected from 1,000 women surveyed user preferences around fertility app characteristics, including aesthetics, features, functionality, and reputation. User knowledge about fertility and reproduction was assessed, and knowledge categories were created. Chi-square tests assessed differences in app characteristic preferences according to knowledge category. Additional qualitative analyses on free-text answers explored which features of apps are important to users when they search for one to use.
Approximately one quarter (23.1%) of survey respondents reported currently using a fertility app or had used one in the recent past, and 76.9% reported intention to use one in the future. A majority of both current and intended users (65.4%) had some knowledge of fertility and reproduction, while 16.5% had very little knowledge. 18.1% reported receiving prior provider counseling on using a fertility-awareness based method. Users across all knowledge groups said it was very important for apps to be science-based and that they identify fertile days during the menstrual cycle.
Women who use or wish to use apps to prevent pregnancy are seeking apps that are scientifically sound and provide them personalized information around their potential fertility. However, most fertility apps women reported using lack the capability for true fertility-awareness based method application for accurate, reliable pregnancy prevention. More research is needed to evaluate apps for efficacy and accuracy preventing pregnancy. Collaborations between app developers and women's health experts are encouraged, as well as informed consumerism campaigns.
Duane M et al., 2016·J Am Board Fam Med·Free to read
In recent years there has been an explosion in the development of medical apps, with more than 40,000 apps now available. Nearly 100 apps allow women to track their fertility and menstrual cycles and can be used to avoid or achieve pregnancy. Apps offer a convenient way to track fertility biomarkers. However, only some use evidence-based fertility awareness-based methods (FABMs), which with ideal use have rates of effectiveness similar to those of commonly used forms of hormonal birth control. Since having a baby or preventing a pregnancy are important responsibilities, it is critical that women and couples have access to reliable, evidence-based apps that allow them to accurately track their fertility. We developed a tool to evaluate and rate fertility apps. This tool is specifically designed to help couples avoid pregnancy. Results showed that the majority of fertility apps are not based on evidence-based FABMs or include a disclaimer discouraging use for avoiding pregnancy. However, at least 1 app in each FABM category (except symptohormonal methods) had a perfect score on accuracy. Relying solely on an app to use an FABM, without appropriate training in the method, may not be sufficient to prevent pregnancy.
Costa Figueiredo M et al., 2021·JAMIA Open·Free full text on PubMed Central
Fertility is becoming increasingly supported by consumer health technologies, especially mobile apps that support self-tracking activities. However, it is not clear whether the apps support the variety of goals and life events of those who menstruate, especially during transitions between them. Thirty-one of the most popular fertility apps were evaluated, analyzing data from three sources: the content of app store pages, app features, and user reviews. Findings: Results suggest that fertility apps are designed to support specific life goals of people who menstruate, offering several data collection features and limited feedback options. However, users often desire holistic tracking that encompasses a variety of goals, life events, and the transitions among them. These findings suggest fertility patients can benefit more from holistic self-tracking and provide insights for future design of consumer health technologies that better support holistic fertility tracking. Fertility apps have the potential to support varied experiences of people who menstruate. But to achieve that, apps need to expand their support by offering ways for more users to perform holistic, personalized, and personally meaningful tracking, so they can derive long-term benefit from the data they collect.
Fertility Awareness › Technology › Cycle Tracking Apps · Cost and Access › Population and Global Health › Low Resource Settings
Liya T Haile, Hanley M Fultz, Rebecca G Simmons, Victoria Shelus
L Haile, H Fultz, Becky Simmons, R Simmons, V Shelus
PMID 30148140 30148140 DOI 10.21037/mhealth.2018.06.07 10.21037/mhealth.2018.06.07 Haile et al. 2018, Haile 2018
Cite this article
Haile, L. T., Fultz, H. M., Simmons, R. G., & Shelus, V. (2018). Market-testing a smartphone application for family planning: assessing potential of the CycleBeads app in seven countries through digital monitoring. mHealth. https://doi.org/10.21037/mhealth.2018.06.07
Haile LT, Fultz HM, Simmons RG, Shelus V. Market-testing a smartphone application for family planning: assessing potential of the CycleBeads app in seven countries through digital monitoring. mHealth. 2018. doi:10.21037/mhealth.2018.06.07
