Patterns and trends in contraceptive use among women attending Title X clinics and a national sample of low-income women.

OBJECTIVES: To describe the types of contraception used by women attending Title X-funded clinics and a comparable group of low-income reproductive-age women at risk of unintended pregnancy. STUDY DESIGN: We estimated the percentage of reproductive aged (15-44 years) women using contraception, by method type and level of effectiveness in preventing pregnancy (i.e., most, moderately, and less effective), using Title X Family Planning Annual Report (2006-2016) and National Survey of Family Growth (2006-2015) data. We divided most effective methods into permanent (female and male sterilization) and reversible (long-acting reversible contraceptives [LARCs]) methods. RESULTS: Among Title X clients during 2006-2016, use of LARCs increased (3-14%); use of moderately effective methods decreased (64-54%); and use of sterilization (~ 2%), less effective methods (21-20%), and no method (8-7%) was unchanged. These same trends in contraceptive use were observed in a comparable group of women nationally during 2006-2015, during which LARC use increased (5-19%, p < .001); moderately effective method use decreased (60-48%, p < .001); and use of sterilization (~5%), less effective methods (19%), and no method (11-10%) was unchanged. CONCLUSIONS: The contraceptive method mix among Title X clients differs from that of low-income women at risk of unintended pregnancy nationally, but general patterns and trends are similar in the two populations. Research is needed to understand whether method use patterns among low-income women reflect their preferences, access, or the conditions of the supply environment. IMPLICATIONS: This study contributes to our understanding of patterns and trends in contraceptive use among two groups of reproductive-age women - Title X clients and low-income women nationally who are at risk of unintended pregnancy. The findings highlight areas for further research.

Client Preferences for Contraceptive Counseling: A Systematic Review.

CONTEXT: Providers can help clients achieve their personal reproductive goals by providing high-quality, client-centered contraceptive counseling. Given the individualized nature of contraceptive decision making, provider attention to clients' preferences for counseling interactions can enhance client centeredness. The objective of this systematic review was to summarize the evidence on what preferences clients have for the contraceptive counseling they receive. EVIDENCE ACQUISITION: This systematic review is part of an update to a prior review series to inform contraceptive counseling in clinical settings. Sixteen electronic bibliographic databases were searched for studies related to client preferences for contraceptive counseling published in the U.S. or similar settings from March 2011 through November 2016. Because studies on client preferences were not included in the prior review series, a limited search was conducted for earlier research published from October 1992 through February 2011. EVIDENCE SYNTHESIS: In total, 26 articles met inclusion criteria, including 17 from the search of literature published March 2011 or later and nine from the search of literature from October 1992 through February 2011. Nineteen articles included results about client preferences for information received during counseling, 13 articles included results about preferences for the decision-making process, 13 articles included results about preferences for the relationship between providers and clients, and 11 articles included results about preferences for the context in which contraceptive counseling is delivered. CONCLUSIONS: Evidence from the mostly small, qualitative studies included in this review describes preferences for the contraceptive counseling interaction. Provider attention to these preferences may improve the quality of family planning care; future research is needed to explore interventions designed to meet preferences. THEME INFORMATION: This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

Clinic-Based Programs to Prevent Repeat Teen Pregnancy: A Systematic Review.

CONTEXT: The purpose of this paper is to synthesize and evaluate the evidence on the effectiveness of repeat teen pregnancy prevention programs offered in clinical settings. EVIDENCE ACQUISITION: Multiple databases were searched for peer-reviewed articles published from January 1985 to April 2016 that included key terms related to adolescent reproductive health services. Analysis of these studies occurred in 2017. Studies were excluded if they focused solely on sexually transmitted disease/HIV prevention services, or occurred outside of a clinic setting or the U.S., Canada, Europe, Australia, or New Zealand. Inclusion and exclusion criteria further narrowed the studies to those that included information on at least one short-term (e.g., increased knowledge); medium-term (e.g., increased contraceptive use); or long-term (e.g., decreased repeat teen pregnancy) outcome, or identified contextual barriers or facilitators for providing adolescent-focused family planning services. Standardized abstraction methods and tools were used to synthesize the evidence and assess its quality. Only studies of clinic-based programs focused on repeat teen pregnancy prevention were included in this review. EVIDENCE SYNTHESIS: The search strategy identified 27,104 citations, 940 underwent full-text review, and 120 met the adolescent-focused family planning services inclusion criteria. Only five papers described clinic-based programs focused on repeat teen pregnancy prevention. Four studies found positive (n=2) or null (n=2) effects on repeat teen pregnancy prevention; an additional study described facilitators for helping teen mothers remain linked to services. CONCLUSIONS: This review identified clinic-based repeat teen pregnancy prevention programs and few positively affect factors that may reduce repeat teen pregnancy. Access to immediate postpartum contraception or home visiting programs may be opportunities to meet adolescents where they are and reduce repeat teen pregnancy. THEME INFORMATION: This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

Trends in Cervical Cancer Screening in Title X-Funded Health Centers - United States, 2005-2015.

Cervical cancer screening is critical to early detection and treatment of precancerous cells and cervical cancer. In 2015, 83% of U.S. women reported being screened per current recommendations, which is below the Healthy People 2020 target of 93% (1,2). Disparities in screening persist for women who are younger (aged 21-30 years), have lower income, are less educated, are uninsured, lack a source of health care, or who self-identify as Asian or American Indian/Alaska Native (2). Women who are never screened or rarely screened are more likely to develop cancer and receive a cancer diagnosis at later stages than women who are screened regularly (3). In 2013, cervical cancer was diagnosed in 11,955 women in the United States, and 4,217 died from the disease (4). Aggregated administrative data from the Title X Family Planning Program were used to calculate the percentage of female clients served in Title X-funded health centers who received a Papanicolaou (Pap) test during 2005-2015. Trends in the percentage of Title X clients screened for cervical cancer were examined in relation to changes in cervical cancer screening guidelines, particularly the 2009 American College of Obstetricians and Gynecologists (ACOG) update that raised the age for starting cervical cancer screening to 21 years (5) and the 2012 alignment of screening guidelines from ACOG, the U.S. Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS) on the starting age (21 years), screening interval (3 or 5 years), and type of screening test (6-8). During 2005-2015, the percentage of female clients screened for cervical cancer dropped continually, with the largest declines occurring in 2010 and 2013, notably a year after major updates to the recommendations. Although aggregated data contribute to understanding of cervical cancer screening trends in Title X centers, studies using client-level and encounter-level data are needed to assess the appropriateness of cervical cancer screening in individual cases.

From theory to application: using performance measures for contraceptive care in the Title X family planning program.

OBJECTIVE: The objective was to describe a Performance Measure Learning Collaborative (PMLC) designed to help Title X family planning grantees use new clinical performance measures for contraceptive care. STUDY DESIGN: Twelve Title X grantee-service site teams participated in an 8-month PMLC from November 2015 to June 2016; baseline was assessed in October 2015. Each team documented their selected best practices and strategies to improve performance, and calculated the contraceptive care performance measures at baseline and for each of the subsequent 8 months. RESULTS: PMLC sites implemented a mix of best practices: (a) ensuring access to a broad range of methods (n=7 sites), (b) supporting women through client-centered counseling and reproductive life planning (n=8 sites), (c) developing systems for same-day provision of all methods (n=10 sites) and (d) utilizing diverse payment options to reduce cost as a barrier (n=4 sites). Ten sites (83%) observed an increase in the clinical performance measures focused on most and moderately effective methods (MME), with a median percent change of 6% for MME (from a median of 73% at baseline to 77% post-PMLC). CONCLUSION: Evidence suggests that the PMLC model is an approach that can be used to improve the quality of contraceptive care offered to clients in some settings. Further replication of the PMLC among other groups and beyond the Title X network will help strengthen the current model through lessons learned. IMPLICATIONS: Using the performance measures in the context of a learning collaborative may be a useful strategy for other programs (e.g., Federally Qualified Health Centers, Medicaid, private health plans) that provide contraceptive care. Expanded use of the measures may help increase access to contraceptive care to achieve national goals for family planning.

The Link Between Reproductive Life Plan Assessment And Provision of Preconception Care At Publicly Funded Health Centers.

CONTEXT: Federal and clinical guidelines recommend integrating reproductive life plan assessments into routine family planning encounters to increase provision of preconception care. Yet, the prevalence of clinical protocols and of relevant practices at publicly funded health centers is unknown. METHODS: Administrators and providers at a nationally representative sample of publicly funded health centers that provide family planning services were surveyed in 2013-2014; data from 1,039 linked pairs were used to explore the reported prevalence of reproductive life plan protocols, frequent assessment of patients' reproductive life plan and frequent provision of preconception care. Chi-square tests and multivariable general linear models were used to examine differences in reports of protocols and related practices. RESULTS: Overall, 58% of centers reported having reproductive life plan assessment protocols, 87% reported frequently assessing reproductive life plans and 55% reported frequently providing preconception care. The proportions reporting protocols were lower in community health centers than in other center types (32% vs. 52-91%), in primary care centers than in those with another focus (33% vs. 77-80%) and in centers not receiving Title X funding than in those with such support (36% vs. 77%). Reported existence of a written protocol was positively associated with reported frequent assessment (prevalence ratio, 1.1), and the latter was positively associated with reported frequent preconception care (1.4). CONCLUSION: Further research is needed on associations between written protocols and clinical practice, and to elucidate the preconception care services that may be associated with reproductive life plan assessment.

Four aspects of the scope and quality of family planning services in US publicly funded health centers: Results from a survey of health center administrators.

OBJECTIVES: This study aims to describe aspects of the scope and quality of family planning services provided by US publicly funded health centers before the release of relevant federal recommendations. STUDY DESIGN: Using nationally representative survey data (N=1615), we describe four aspects of service delivery: family planning services provided, contraceptive methods provided onsite, written contraceptive counseling protocols and youth-friendly services. We created a count index for each issue and used multivariable ordered logistic regression to identify health center characteristics associated with scoring higher on each. RESULTS: Half of the sample received Title X funding and about a third each were a community health center or health department clinic. The vast majority reported frequently providing contraceptive services (89%) and STD services (87%) for women in the past 3 months. Service provision to males was substantially lower except for STD screening. A total of 63% and 48% of health centers provided hormonal IUDs and implants onsite in the past 3 months, respectively. Forty percent of health centers included all five recommended contraceptive counseling practices in written protocols. Of youth-friendly services, active promotion of confidential services was among the most commonly reported (83%); offering weekend/evening hours was among the least (42%). In multivariable analyses, receiving Title X funding, having larger volumes of family planning clients and being a Planned Parenthood clinic were associated with higher scores on most indices. CONCLUSION: Many services were consistent with the recommendations for providing quality family planning services, but there was room for improvement across domains and health centers types. IMPLICATIONS STATEMENT: As assessed in this paper, the scope and quality of these family planning services was relatively high, particularly among Planned Parenthood clinics and Title X-funded centers. However, results point to important areas for improvement. Future studies should assess change as implementation of recent family planning service recommendations continues.

Preconception Care in Publicly Funded U.S. Clinics That Provide Family Planning Services.

INTRODUCTION: Federal recommendations for providing quality family planning services were published in 2014 and included preconception care (PCC). This paper aims to describe the prevalence of PCC delivery among publicly funded clinics, prior to the recommendations. METHODS: Prevalence of providing occasional or frequent PCC in the last 3 months and having written protocols for recommended PCC screenings were estimated in 2015 using survey data collected from a nationally representative sample of publicly funded clinic administrators (2013-2014, N=1,615). Analyses included examination of differential distributions of outcomes by clinic characteristics (p<0.05) and multivariable regression. RESULTS: Prevalence of occasional or frequent PCC delivery was 81% for women and 38% for men. The percentage of clinics with written protocols for specific PCC screenings ranged from 74% to 88% (women) and 66% to 83% (men). Prevalence of having written protocols for all PCC screenings was 29% for women and 22% for men. Characteristics negatively associated with having written protocols for all PCC screenings for women and men (respectively) were as follows: not receiving Title X funding (adjusted prevalence ratio [APR]=0.6, 95% CI=0.50, 0.76; APR=0.6, 95% CI=0.47, 0.77) and being a community health center (APR=0.5, 95% CI=0.37, 0.72; APR=0.5, 95% CI=0.30, 0.67); health department (APR=0.7, 95% CI=0.61, 0.87; APR=0.6, 95% CI=0.49, 0.76); or hospital/other (APR=0.6, 95% CI=0.50, 0.79; APR=0.6, 95% CI=0.43, 0.75) (versus Planned Parenthood). CONCLUSIONS: Provision of PCC appears to differ by clinic characteristics and by interpretation of the phrase "preconception care," suggesting opportunities for education and improvement.

Community Education for Family Planning in the U.S.: A Systematic Review.

CONTEXT: Community education may involve activities that seek to raise awareness and promote behavior change, using mass media, social media, and other media or interpersonal methods in community settings. This systematic review evaluated the evidence of the effects of community education on select short- and medium-term family planning outcomes. EVIDENCE ACQUISITION: Using an analytic approach drawn from the U.S. Preventive Services Task Force, multiple databases were searched for articles published from January 1985 through February 2011 describing studies of community education related to family planning in the U.S. Included articles were reviewed and assessed for potential bias using a standardized process in 2011. An updated, targeted review for the 2011-2014 period was conducted in early 2015. EVIDENCE SYNTHESIS: Seventeen papers were identified. Most (nine) related to mass media interventions; three involved targeted print media, two involved text messaging or e-mail, two described outcome workers conducting community education, and one involved community theater. Study designs, strength of evidence, and levels of possible bias varied widely. Twelve of 15 studies that addressed outcomes such as increased awareness found positive associations with those outcomes, with six also reporting null findings. Seven of eight studies that addressed use of services reported positive associations, with two also reporting null findings. The targeted, additional review identified two other studies. CONCLUSIONS: Evidence related to community education for family planning purposes is limited and highly variable. As goals of community education are usually limited to shorter-term outcomes, the evidence suggests that a range of approaches may be effective.

Developing Federal Clinical Care Recommendations for Men.

U.S. men experience substantial sexual and reproductive health needs across the life span. A significant barrier for providers in serving men in family planning, primary care, and sexually transmitted disease clinics has been the lack of standards for men's sexual and reproductive health care. The goal of this synthesis paper is to describe the development of clinical recommendations for the delivery of family planning services for men that were developed and published by CDC and the U.S. Office of Population Affairs. This paper is intended to describe the process used from 2011 to 2014 to develop the recommendations for the delivery of comprehensive reproductive healthcare services to men, and the rationale underpinning them.

Developing Federal Clinical Care Recommendations for Women.

UNLABELLED: The provision of family planning services has important health benefits for the U.S. POPULATION: Approximately 25 million women in the U.S. receive contraceptive services annually and 44 million make at least one family planning-related clinical visit each year. These services are provided by private clinicians, as well as publicly funded clinics, including specialty family planning clinics, health departments, Planned Parenthoods, community health centers, and primary care clinics. Recommendations for providing quality family planning services have been published by CDC and the Office of Population Affairs of the DHHS. This paper describes the process used to develop the women's clinical services portion of the new recommendations and the rationale underpinning them. The recommendations define family planning services as contraceptive care, pregnancy testing and counseling, achieving pregnancy, basic infertility care, sexually transmitted disease services, and preconception health. Because many women who seek family planning services have no other source of care, the recommendations also include additional screening services related to women's health, such as cervical cancer screening. These clinical guidelines are aimed at providing the highest-quality care and are designed to establish a national standard for family planning in the U.S.

Confidentiality in Family Planning Services for Young People: A Systematic Review.

CONTEXT: Family planning services are essential for reducing high rates of unintended pregnancies among young people, yet a perception that providers will not preserve confidentiality may deter youth from accessing these services. This systematic review, conducted in 2011, summarizes the evidence on the effect of assuring confidentiality in family planning services to young people on reproductive health outcomes. The review was used to inform national recommendations on providing quality family planning services. EVIDENCE ACQUISITION: Multiple databases were searched to identify articles addressing confidentiality in family planning services to youth aged 10-24 years. Included studies were published from January 1985 through February 2011. Studies conducted outside the U.S., Canada, Europe, Australia, or New Zealand, and those that focused exclusively on HIV or sexually transmitted diseases, were excluded. EVIDENCE SYNTHESIS: The search strategy identified 19,332 articles, nine of which met the inclusion criteria. Four studies examined outcomes. Examined outcomes included use of clinical services and intention to use services. Of the four outcome studies, three found a positive association between assurance of confidentiality and at least one outcome of interest. Five studies provided information on youth perspectives and underscored the idea that young people greatly value confidentiality when receiving family planning services. CONCLUSIONS: This review demonstrates that there is limited research examining whether confidentiality in family planning services to young people affects reproductive health outcomes. A robust research agenda is needed, given the importance young people place on confidentiality.

Collaboration for the integration of HIV prevention at Title X family planning service delivery sites.

Since 2001, the U.S. Department of Health and Human Services' Office of Family Planning (OFP), in collaboration with the Minority AIDS Initiative, has provided supplemental grant funds to Title X-funded family planning service delivery sites to expand the availability of human immunodeficiency virus (HIV) prevention services. This work has resulted in three major outcomes: (1) increased institutional capacity for the delivery of HIV-prevention services at Title X family planning service delivery sites, (2) the successful implementation of HIV-prevention services at these sites, and (3) the identification of HIV-positive individuals who were referred to care services. These efforts resulted in a total of 539,667 unduplicated individuals being tested for HIV. These tests resulted in the identification of 1,692 HIV-positive individuals who otherwise may not have been tested for HIV. More than 85% of the HIV-positive cases were detected among clients who self-identified as members of racial/ethnic minority groups. The integration of HIV-prevention services is a feasible and effective strategy for detecting HIV infection among women, including women in racial/ethnic minority groups.