Background: The federal Title X Family Planning Program supports the delivery of family planning services and related preventive care to 4 million individuals annually in the United States. The implementation of the 2010 Affordable Care Act's (ACA's) Medicaid expansion and provisions expanding access to health insurance, which took effect in January 2014, resulted in higher rates of health insurance coverage in the U.S. population; the ACA's impact on individuals served by the Title X program has not yet been evaluated. Methods: Using administrative data we examined changes in health insurance coverage among Title X clinic patients during 2005-2015. Results: We found that the percentage of clients without health insurance decreased from 60% in 2005 to 48% in 2015, with the greatest annual decrease occurring between 2013 and 2014 (63% to 54%). Meanwhile, between 2005 and 2015, the percentage of clients with Medicaid or other public health insurance increased from 20% to 35% and the percentage of clients with private health insurance increased from 8% to 15%. Conclusions: Although clients attending Title X clinics remained uninsured at substantially higher rates compared with the national average, the increase in clients with health insurance coverage aligns with the implementation of ACA-related provisions to expand access to affordable health insurance.

BACKGROUNDReferrals to other medical services are central to healthcare, including family planning service providers; however, little information exists on the nature of referral practices among health centers that offer family planning.MATERIALS AND METHODSWe used a nationally representative survey of administrators from 1,615 publicly funded health centers that offered family planning in 2013-14 to describe the use of six referral practices. We focused on associations between various health center characteristics and frequent use of three active referral practices.RESULTSIn the prior 3 months, a majority of health centers (73%) frequently asked clients about referrals at clients' next visit. Under half (43%) reported frequently following up with referral sources to find out if their clients had been seen. A third (32%) of all health centers reported frequently using three active referral practices. In adjusted analysis, Planned Parenthood clinics (adjusted odds ratio 0.55) and hospital-based clinics (AOR 0.39) had lower odds of using the three active referral practices compared with health departments, and Title X funding status was not associated with the outcome. The outcome was positively associated with serving rural areas (AOR 1.39), having a larger client volume (AOR 3.16), being a part of an insurance network (AOR 1.42), and using electronic health records (AOR 1.62).CONCLUSIONSPublicly funded family planning providers were heavily engaged in referrals. Specific referral practices varied widely and by type of care. More assessment of these and other aspects of referral systems and practices is needed to better characterize the quality of care.

Objectives: Access to a full range of contraceptive methods, including long-acting reversible contraception (LARC), is central to providing quality family planning services. We describe health center-related factors associated with LARC availability, including staff training in LARC insertion/removal and approaches to offering LARC, whether onsite or through referral. Study Design: We analyzed nationally representative survey data collected during 2013-2014 from administrators of publicly funded U.S. health centers that offered family planning. The response rate was 49.3% (n=1615). In addition to descriptive statistics, we used multivariable logistic regression to identify health center characteristics associated with offering both IUDs and implants onsite. Results: Two-thirds (64%) of health centers had staff trained in all three LARC types (hormonal IUD, copper IUD, implant); 21% had no staff trained in any of those contraceptive methods. Half of health centers (52%) offered IUDs (any type) and implants onsite. After onsite provision, informal referral arrangements were the most common way LARC methods were offered. In adjusted analyses, Planned Parenthood (AOR=9.49) and hospital-based (AOR=2.35) health centers had increased odds of offering IUDs (any type) and implants onsite, compared to Health Departments, as did Title X-funded (AOR=1.55) compared to non-Title X-funded health centers and centers serving a larger volume of family planning clients. Centers serving mostly rural areas compared to those serving urbans areas had lower odds (AOR 0.60) of offering IUD (any type) and implants. Conclusions: Variation in LARC access remains among publicly funded health centers. In particular, Health Departments and rural health centers have relatively low LARC provision. (C) 2017 Elsevier Inc. All rights reserved.

Introduction There is increasing evidence that infection with the Zika virus (ZIKV) during pregnancy can lead to severe brain abnormalities in infants exposed in utero. The objective of our analysis was to estimate the contribution of enhanced contraception access to averting ZIKV-related microcephaly births in the United States, alone and in combination with another possible strategy, anti-ZIKV vaccination. Methods We used Monte Carlo sampling techniques (n = 100,000 simulations) to estimate the number of microcephaly births expected under strategies of enhanced contraception only, vaccination only, both enhanced contraception and vaccination, and status quo (no intervention). Enhanced contraceptive access was assumed to reduce unintended pregnancy rates by 46% and anti-ZIKV vaccination was assumed to be 90% effective. Plausible values for effectiveness of enhanced contraceptive access, ZIKV cumulative incidence, ZIKV-related microcephaly risk, and anti-ZIKV vaccination parameters were derived from the literature or best available knowledge. Results Enhanced contraceptive access alone reduced the median number of ZIKV-related microcephaly births by 16% (95% simulation interval: 5, 23), while the anti-ZIKV vaccine alone reduced these births by 9% (95% SI: 0, 18), 45% (95% SI: 36, 54), and 81% (95% SI: 71, 91), under conservative (10% vaccine uptake), moderate (50% vaccine uptake), and optimistic (90% vaccine uptake) scenarios, respectively. The reduction in ZIKV-related microcephaly births was always greater if both interventions were employed. Discussion Enhanced contraceptive access alone has the ability to produce a meaningful reduction in microcephaly births, and could provide an important adjuvant prevention strategy even following the development of a highly-effective anti-ZIKV vaccine.

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.

In April 2014, CDC published "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs" (QFP), which describes the scope of services that should be offered in a family planning visit and how to provide those services (e.g., periodicity of screening, which persons are in need of services, etc.) (1). The sections in QFP include the following: Determining the Client's Need for Services; Contraceptive Services; Pregnancy Testing and Counseling; Clients Who Want to Become Pregnant; Basic Infertility Services; Preconception Health Services; Sexually Transmitted Disease Services; and Related Preventive Health Services. In addition, the QFP includes an appendix entitled Screening Services for Which Evidence Does Not Support Screening.

In the United States, almost half (45%) of the approximately 6 million pregnancies each year are unintended [ [1] Finer L.B. Zolna M.R. Declines in unintended pregnancy in the United States, 2008–2011. N Engl J Med. 2016; 374: 843-852 Crossref PubMed Scopus (1269) Google Scholar ]. These statistics indicate that many women experience barriers to achieving their desired reproductive outcomes, which has potential adverse consequences for women, children and society at large, such as higher rates of preterm birth, lower rates of breastfeeding and lower educational attainment [ 2 Conde-Agudelo A. Rosas-Bermudez A. Kafury-Goeta A.C. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA. 2006; 295: 1809-1823 Crossref PubMed Scopus (765) Google Scholar , 3 DeFranco E.A. Seske L.M. Greenberg J.M. Muglia L.J. Influence of interpregnancy interval on neonatal morbidity. Am J Obstet Gynecol. 2015; 212: 386.e381-386.e389 Abstract Full Text Full Text PDF Scopus (38) Google Scholar , 4 Gipson J.D. Koenig M.A. Hindin M.J. The effects of unintended pregnancy on infant, child, and parental health: a review of the literature. Stud Fam Plan. 2008; 39: 18-38 Crossref PubMed Scopus (601) Google Scholar , 5 Sawhill I. Karpilow Q. Venator J. Families CoCa The impact of unintended childbearing on future generations. Brookings Institution, Washington, DC2014 Google Scholar , 6 Tsui A.O. McDonald-Mosley R. Burke A.E. Family planning and the burden of unintended pregnancies. Epidemiol Rev. 2010; 32: 152-174 Crossref PubMed Scopus (240) Google Scholar ]. Contraceptive care is a highly effective clinical intervention that can substantially reduce those adverse outcomes, help individuals and couples achieve their desired number and spacing of children, and save money [ 7 Foster D.G. Biggs M.A. Malvin J. Bradsberry M. Darney P. Brindis C.D. Cost-savings from the provision of specific contraceptive methods in 2009. Womens Health Issues. 2013; 23: e265-e271 Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar , 8 Frost J. Finer L. Tapales A. The impact of publicly funded family planning clinic services on unintended pregnancies and government cost savings. J Health Care Poor Underserved. 2008; 19: 778-796 Crossref PubMed Scopus (57) Google Scholar , 9 Frost J.J. Sonfield A. Zolna M.R. Finer L.B. Return on investment: a fuller assessment of the benefits and cost savings of the US publicly funded family planning program. Milbank Q. 2014; 92: 696-749 Crossref PubMed Scopus (61) Google Scholar , 10 Sonfield A. Kost K. Institute TG Public costs from unintended pregnancies and the role of public insurance programs in paying for pregnancy and infant care: estimates for 2010. The Guttmacher Institute, New York, NY2015 Google Scholar , 11 Trussell J. Contraceptive failure in the United States. Contraception. 2011; 83: 397-404 Abstract Full Text Full Text PDF PubMed Scopus (982) Google Scholar ]. However, many women at risk of unintended pregnancy do not use contraception or use it incorrectly or inconsistently [ 12 Daniels K. Daugherty J. Jones J. Mosher W. Current contraceptive use and variation by selected characteristics among women aged 15–44: United States, 2011–2013. US National Center for Health Statistics, Hyattsville, MD2015 Google Scholar , 13 Jones R. Tapales A. Lindberg L. Frost J. Using longitudinal data to understand changes in consistent contraceptive use. Perspect Sex Reprod Health. 2015; 47: 131-139 Crossref PubMed Scopus (36) Google Scholar ], and there are documented barriers in access to and quality of contraceptive care services available [ [14] Obstet Gynecol. 2015; 125: 250-255 Crossref PubMed Google Scholar ].

INTRODUCTION:Family planning providers have an important role to play in the response to the public health challenge posed by Zika. In the United States, there are high rates of unintended pregnancy, especially in states most at risk for mosquito-borne transmission of the Zika virus. This paper describes efforts by eight of these states (Arizona, California, Florida, Georgia, Louisiana, Mississippi, South Carolina, and Texas) to build capacity for quality family planning care in the context of Zika.METHODS:Drawing on resources developed by the Office of Population Affairs, including a toolkit for family planning care in the context of Zika, agencies and stakeholders involved in the family planning delivery system in Southern states at risk for mosquito-borne transmission met over several months in the summer of 2016 to coordinate efforts to respond to the risk of Zika in their jurisdictions.RESULTS:Through proactive communication and collaboration, states took steps to integrate Zika-related family planning care, including screening for Zika risk and providing appropriate, client-centered counseling. Challenges faced by the states included not having family planning included as a component of their state's Zika response effort, limited funding for family planning activities, and the need for robust communication networks between multiple state and federal agencies.CONCLUSIONS:The efforts described in this paper can help other states to integrate family planning into their Zika response. This is relevant to all states; even when mosquito-borne transmission is not occurring or expected, all states experience travel-related and sexually transmitted Zika infections.

Contraception is an essential health service for reducing unintended pregnancy rates, improving health outcomes, and reducing health care costs. However, contraceptive services may not consistently provide access to the full method mix and to patient-centered care. Improving the quality of contraceptive care is a critical strategy to improve contraceptive use, health outcomes, and the patient experience of care. We here describe the three National Quality Forum-endorsed performance measures for contraceptive care, which are intended to monitor 1) provision of most and moderately effective methods, 2) access to long-acting reversible contraception, and 3) provision of most and moderately effective methods and access to long-acting reversible contraception after childbirth. These contraceptive care measures are designed to ensure that contraceptive care is accessible and offers the full spectrum of methods. Payers, health care systems, public agencies, and researchers could all monitor these performance measures for different populations. We describe the crucial role of clinicians in disseminating and using the contraceptive care performance measures for quality improvement. We describe ongoing efforts to improve contraceptive care quality, including the development of measures to monitor other dimensions of quality such as the safety and patient-centeredness of care. Thirty-eight million women at risk of unintended pregnancy are counting on us to improve the quality of family planning care in the United States and ensure that all women have the resources and tools to make free, informed choices about whether and when to become pregnant.

CONTEXTThe United Nations Sustainable Development Goals (SDGs) seek to achieve health equity, and they apply to all countries. SDG contraceptive use estimates for the United States are needed to contextualize U.S. performance in relation to that of other countries. METHODSData from the 2011-2013 and 2013-2015 waves of the National Survey of Family Growth were used to calculate three SDG indicators of contraceptive use for U.S. women aged 15-44: contraceptive prevalence, unmet need for family planning and demand for family planning satisfied by modern methods. These measures were calculated separately for married or cohabiting women and for unmarried, sexually active women; differences by sociodemographic characteristics were assessed using t tests from logistic regression analysis. Estimates for married women were compared with 2010-2015 estimates from 94 other countries, most of which were low- or middle-income. RESULTSFor married or cohabiting women, U.S. estimates for contraceptive prevalence, unmet need and demand satisfied by modern methods were 74%, 9% and 80%, respectively; for unmarried, sexually active women, they were 85%, 11% and 82%, respectively. Estimates varied by sociodemographic characteristics, particularly among married or cohabiting women. Five countries performed better than the United States on contraceptive prevalence, 12 on unmet need and four on both measures; seven performed better on demand satisfied by modern methods. CONCLUSIONSThere is a need to continue efforts to expand access to contraceptive care in the United States, and to monitor the SDG indicators so that improvement can be tracked over time.

Objectives: In November 2016, the National Quality Forum endorsed claims-based clinical performance measures for most or moderately effective contraception and LARC. Complementary performance measures that utilize electronic health record (EHR) data are in development to improve both the numerator and the denominator of women who are not at risk for unintended pregnancy. We compared three versions of the measures: EHR only, hybrid (claims+EHR) and claims only.

Objectives: Patient-centeredness is uniquely crucial in contraceptive care due to the personalized nature of contraceptive decision making. We sought to create a parsimonious version of the existing 11-item Interpersonal Quality of Family Planning (IQFP) scale in preparation for testing its appropriateness as a patient-reported outcome performance measure

Objectives The National Quality Forum (NQF) recently endorsed the first clinical performance measures for contraceptive care. We present data demonstrating that the measures meet the NQF's criterion “importance to measure and report.” Study design We summarized national contraceptive care initiatives, epidemiologic data documenting the reproductive health burden and the scientific literature examining the association between contraceptive use and unintended pregnancy. In addition, we analyzed contraceptive use data from the National Survey of Family Growth (2013–2015) and the Pregnancy Risk Assessment Monitoring System (2012–2013). Results Five Federal agencies lead national initiatives, and two Institute of Medicine reports highlight the centrality of reproductive health outcomes for the health of women and infants. Two literature reviews demonstrate that the type of contraception used is associated with risk of unintended pregnancy. Fifty-three percent of adolescents (15–19 years) and 40% of adult women (20–44 years) at risk of unintended pregnancy are not using a most or moderately effective contraceptive method; in the postpartum period, one third of adolescents (≤19 years) and 44% of adult women (≥20 years) are not using these methods. Conclusions The new contraceptive care measures meet the NQF criterion for “importance to measure and report.” The measures are based on evidence that contraceptive use is associated with reproductive health outcomes, and there is a substantial performance gap in the use of most and moderately effective methods. Implications Using the new contraceptive care measures may motivate providers to increase access to contraceptive care, thereby improving health outcomes.

ObjectivesThis 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 designUsing 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.ResultsHalf 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.ConclusionMany 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 statementAs 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.

Purpose In recognition of the importance of performance measurement and MCH epidemiology leadership to quality improvement (QI) efforts, a plenary session dedicated to this topic was presented at the 2014 CityMatCH Leadership and MCH Epidemiology Conference. This paper summarizes the session and provides two applications of performance measurement to QI in MCH. Description Performance measures addressing processes of care are ubiquitous in the current health system landscape and the MCH community is increasingly applying QI processes, such as Plan-Do-Study-Act (PDSA) cycles, to improve the effectiveness and efficiency of systems impacting MCH populations. QI is maximally effective when well-defined performance measures are used to monitor change. Assessment MCH epidemiologists provide leadership to QI initiatives by identifying population-based outcomes that would benefit from QI, defining and implementing performance measures, assessing and improving data quality and timeliness, reporting variability in measures throughout PDSA cycles, evaluating QI initiative impact, and translating findings to stakeholders. MCH epidemiologists can also ensure that QI initiatives are aligned with MCH priorities at the local, state and federal levels. Two examples of this work, one highlighting use of a contraceptive service performance measure and another describing QI for peripartum hemorrhage prevention, demonstrate MCH epidemiologists’ contributions throughout. Challenges remain in applying QI to complex community and systems-level interventions, including those aimed at improving access to quality care. Conclusion MCH epidemiologists provide leadership to QI initiatives by ensuring they are data-informed and supportive of a common MCH agenda, thereby optimizing the potential to improve MCH outcomes.

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 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine

In 2014, CDC published Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs (QFP), which describes the scope of services that should be offered in a family planning visit, and how to provide those services (e.g., periodicity of screening, which persons are considered to be at risk, etc.). The sections in QFP include Contraceptive Services, Pregnancy Testing and Counseling, Clients Who Want to Become Pregnant, Basic Infertility Services, Preconception Health Services, Sexually Transmitted Disease Services, Related Preventive Health Services, and Screening Services for Which Evidence Does Not Support Screening.

The Zika virus is a newly emerging threat to women's reproductive health that is receiving increasing international and domestic attention. This virus can be passed from a pregnant woman to her fetus and cause microcephaly as well as other severe brain anomalies, and has also been linked to problems such as defects of the eye and pregnancy loss [ 1 Petersen LR Jamieson DJ Powers AM Honein MA Zika virus. N Engl J Med. 2016; 374: 1552-1563 Crossref PubMed Scopus (887) Google Scholar , 2 Rasmussen SA Jamieson DJ Honein MA Petersen LR Zika virus and birth defects—reviewing the evidence for causality. N Engl J Med. 2016; 374: 1981-1987 Crossref PubMed Scopus (1342) Google Scholar ]. Zika is transmitted both through the bites of Aedes species mosquitoes and through sex with a person who has been infected with Zika, and the virus has been circulating in South and Central America and the Caribbean (including Puerto Rico) since 2015. The first case of mosquito-borne transmission in the United States occurred in June 2016.

From 2010 to 2014, CDC and the Office of Population Affairs at the USDHHS collaborated on the development of clinical recommendations for providing quality family planning services. A high priority was placed on the use of existing scientific evidence in developing the recommendations, in accordance with IOM guidelines for how to develop "trustworthy" clinical practice guidelines. Consequently, a series of systematic reviews were developed using a transparent and reproducible methodology aimed at ensuring that the clinical practice guidelines would be based on evidence collected in the most unbiased manner possible. This article describes the methodology used in conducting these systematic reviews, which occurred from mid-2011 through 2012. From 2010 to 2014, CDC and the Office of Population Affairs at the USDHHS collaborated on the development of clinical recommendations for providing quality family planning services. A high priority was placed on the use of existing scientific evidence in developing the recommendations, in accordance with IOM guidelines for how to develop "trustworthy" clinical practice guidelines. Consequently, a series of systematic reviews were developed using a transparent and reproducible methodology aimed at ensuring that the clinical practice guidelines would be based on evidence collected in the most unbiased manner possible. This article describes the methodology used in conducting these systematic reviews, which occurred from mid-2011 through 2012.