Postpartum Charting: Marquette or Billings

If you have started to research fertility awareness methods for postpartum, you have likely come across the Marquette or Billings debate. As someone who has used both methods postpartum, they definitely both have pros/cons and it is important to pick the right method for your life, because the most effective method is one you will use. Before comparing the two methods, we need to understand why these two methods are the best suited for postpartum.

Postpartum Ovulation

In a non-breastfeeding postpartum woman, ovulation almost always occurs before the first bleed. Prolactin release during breastfeeding suppresses FSH release in the brain. FSH is responsible for triggering follicle development in the ovary, which is how prolactin prevents ovulation. In breastfeeding individuals, before 6 months it’s more likely a bleed will occur before ovulation. After 6 months it’s more likely ovulation will occur before the first bleed (Eslami et al).

Since postpartum fertility can take months or years to return, we have to look for signs of oncoming ovulation, as we cannot rely on calendar rules that work in normal cycles. When prolactin no longer sufficiently suppresses FSH, a wave of follicles will begin to develop releasing estrogen. So to use fertility awareness postpartum, we need to watch for rising estrogen to indicate follicular development that could end in ovulation. Cervical mucus and urinary hormones are the two biomarkers used in fertility awareness methods to indicate an estrogen rise.

Postpartum FAM

Marquette is a hormonal method, utilizing the clearblue monitor to give a qualitative assessment of urinary estrogen and LH (use of the Mira monitor is still being studied by Marquette at this time). Billings is a mucus only method, focusing on observing sensation at the vulva. Marquette Method (Bouchard et al) and Billings Ovulation Method (Perez et al) both have postpartum studies, with approximately 98% efficacy. The sympto-thermal method has smaller studies in the postpartum period. The real benefit of sympto-thermal in regular cycles is the double check, however in the postpartum period you cannot use the calendar rules, and temperature can be un-reliable due to frequent night waking (for my tips on temping postpartum check out my blog Charting Basal Body Temperature). In postpartum, the sympto-thermal rules are just a variation on the Billings rules.

As a instructor in both sympto-thermal and Billings, I find sympto-thermal can require un-necessary abstinence postpartum. This is because sympto-thermal only allows for a basic-infertile-pattern of white discharge postpartum, but many women see clear discharge postpartum due to vaginal cell sloth, cervical ectropian, or other normal variations. Billings accounts for variation in basic-infertile-pattern from woman to woman, allowing more available days especially later postpartum when baseline estrogen can be higher. Most other FAM methods use the Billings rules postpartum, without the same nuance or instructor training for mucus analysis.

Marquette vs Billings

Personally I have used both Maquette and Billings Methods postpartum, and I teach Billings. They both have pros and cons. Again the most effective method is the one you will use. Both methods require working with an instructor for full efficacy, which will include follow up chart reviews.

Billings

• Billings does not have recurring cost after instruction.

• Instruction must be face to face with an instructor, there is no pre-recorded/self paced option.

• Requires attention to discharge throughout the day, which can be easily forgotten in the depths of postpartum.

• Billings only allows alternate evenings for intercourse during the infertile window.

• If there is an estrogen rise, intercourse is available after 4 days of returned basic infertile pattern.

Marquette

• Instruction can be face to face with an instructor, pre-recoded, or self paced.

• Marquette can cost $30-60 per month for test strips (at the peak of Covid they were 90 or unavailable).

• Only requires remembering to test in a 4 hr window each morning.

• Marquette allows any time of day, every day during the infertile window.

• Any estrogen increase can lead to a 10+ day period of abstinence. This may be mitigated by the introduction of Mira, but it is still being studied and more expensive.

Many people thrive with the simplicity of Marquette postpartum, since they just have to remember to test their urine each morning. However, as postpartum infertility extends past 6 months, many women find their baseline estrogen increases enough to trigger the monitor leading to extremely long periods of abstinence with Marquette (this is a limitation of how the monitor works, but 50 days is not unheard of). This long period may result in frustration and subsequent pregnancy from breaking the rules (ask me how I know). Since Billings fertility status is based on the daily mucus observations, it is more flexible to when estrogen baseline changes or rises and falls again, potentially providing more available days later postpartum.

Personally I had a lot of issues with the Clearblue monitor, I bought mine used to save money. During my first postpartum I ended up having to send it back to Clearblue due to frequent errors. They sent me back a new one (after a month without a monitor) and it was determined I had a faulty box of test strips and that was the issue. Marquette was often convenient, but the 10 day rule towards the end of cycle 0, then having to reset the monitor for long cycles in cycle 1 and 2 was extremely frustrating. My second postpartum I again occasionally had faulty test strips. Speaking to a few Marquette instructors, this is not a normal occurrence, I just got really unlucky. After around 6 months my second postpartum I switched to Billings, first working with an instructor, then certifying myself.

The morning and daily availability with Marquette was convenient early postpartum. However as estrogen began to rise with less prolactin, the 10 day rule lead to long periods of abstinence. Billings definitely requires more mental effort, remembering to observe and chart each day, which can be challenging with postpartum sleep deprivation. Although the alternate evenings rule was inconvenient at times, it also provided opportunities for planning an early bedtime or working on our separate hobbies on unavailable evenings.

The Right Method

There is no "right" method for postpartum. Some methods work better for different people. Sometimes different periods of your life requires a different method. With similar postpartum efficacy, you really cannot go wrong between choosing Marquette or Billings postpartum. Choose what works for you, and don't be afraid to reach out to an instructor or change methods if its not working!