Editing Pearl Index (section)

==Criticisms==
Like all measures of birth control effectiveness, the Pearl Index is a calculation based on the observations of a given sample population. Thus, studies of different populations using the same contraceptive will yield different values for the index.  The culture and demographics of the population being studied, and the instruction technique used to teach the method, have significant effects on its failure rate.<ref name=Trussel1990>{{cite journal | author= Trussell J | title= A guide to interpreting contraceptive efficacy studies | journal= Obstetrics and Gynecology | year= 1990 | volume= 76 |  pages= 558–567 | pmid=2199875 | issue= 3 Pt 2 |name-list-style=vanc| author2= Hatcher RA | author3= Cates W | display-authors= 3 | last4= Stewart | first4= FH | last5= Kost | first5= K }}</ref><ref name=Trussel1991>{{cite journal | author= Trussell J | title= Methodological pitfalls in the analysis of contraceptive failure | journal=Statistics in Medicine | year=1991 | volume=10 | pages=201–220 | pmid= 2052800  | doi = 10.1002/sim.4780100206 | issue= 2}}</ref>

The Pearl Index has unique shortcomings, however.  It assumes a constant failure rate over time.  That is an incorrect assumption for two reasons: first, the most fertile couples will get pregnant first.  Couples remaining later in the study are, on average, of lower fertility.  Second, most birth control methods have better effectiveness in more experienced users.  The longer a couple is in the study, the better they are at using the method.  So the longer the study length, the lower the Pearl Index will be – and comparisons of Pearl Indexes from studies of different lengths cannot be accurate.<ref>{{Citation |last=Burkman |first=RONALD T. |title=82 - Use of Oral Contraceptives for Contraception |date=2004-01-01 |url=https://www.sciencedirect.com/science/article/pii/B9780124409057503546 |work=Principles of Gender-Specific Medicine |pages=889–898 |editor-last=Legato |editor-first=Marianne J. |access-date=2023-12-19 |place=San Diego |publisher=Academic Press |doi=10.1016/b978-012440905-7/50354-6 |isbn=978-0-12-440905-7 |last2=Dardano |first2=KRISTIN L.}}</ref>

The Pearl Index also provides no information on factors other than accidental pregnancy which may influence effectiveness calculations, such as:
* dissatisfaction with the method
* trying to achieve pregnancy
* medical side effects
* being lost to follow-up

A common misperception is that the highest possible Pearl Index is 100 – i.e. 100% of women in the study conceive in the first year.  However, if all the women in the study conceived in the first month, the study would yield a Pearl Index of 1200 or 1300.  The Pearl Index is only accurate as a statistical estimation of per-year risk of pregnancy if the pregnancy rate in the study was very low.

In 1966, two birth control statisticians advocated abandonment of the Pearl Index:<ref name=Sheps1966>{{cite journal | author= Sheps MC | title= Characteristics of a ratio used to estimate failure rates: occurrences per person year of exposure | journal=Biometrics | year= 1966 | volume= 22 |  pages= 310–321 | pmid=5961447  | doi = 10.2307/2528521 | issue= 2 | publisher= Biometrics, Vol. 22, No. 2 | jstor= 2528521}}</ref><ref name=Potter1966>{{cite journal | author= Potter RG | title= Application of life table techniques to measurement of contraceptive effectiveness | journal=Demography | year=1966 | volume=3 | issue=2 | pages= 297–304 | doi = 10.2307/2060159 | publisher= Demography, Vol. 3, No. 2 | jstor=2060159 | pmid= 21318704| s2cid= 29307911 | doi-access= free }}</ref>
{{quotation|[The Pearl Index] does not serve as an estimator of any quantity of interest, and comparisons between groups may be impossible to interpret... The superiority of life table methods or other estimators that do not assume a constant hazard rate seems clear.<ref>{{cite book | first=John | last=Kippley |author2=Sheila Kippley | year=1996 | title=The Art of Natural Family Planning | edition=4th addition | publisher=The Couple to Couple League | location=Cincinnati, OH | isbn=0-926412-13-2 | pages=140–141 }}</ref>}}