Feasibility study of family planning services screening as clinical decision support at an urban Federally Qualified Health Center network

Objective

The objective was to assess the feasibility of an intervention introducing family planning services screening clinical decision support to improve provision of contraception and/or preconception services for women of reproductive age in our primary care Federally Qualified Health Center (FQHC) network.

Availability of Services Related to Achieving Pregnancy in U.S. Publicly Funded Family Planning Clinics

BackgroundRecognizing that quality family planning services should include services to help clients who want to become pregnant, the objective of our analysis was to examine the distribution of services related to achieving pregnancy at publicly funded family planning clinics in the United States.MethodsA nationally representative sample of publicly funded clinics was surveyed in 2013–2014 (n = 1615). Clinic administrators were asked about several clinical services and screenings related to achieving pregnancy: basic infertility services, reproductive life plan assessment, screening for body mass index, screening for sexually transmitted diseases, provision of natural family planning services, infertility treatment, and primary care services. The percentage of clinics offering each of these services was compared by Title X funding status; prevalence ratios (PRs) and 95% confidence intervals (CIs) were estimated after adjusting for clinic characteristics.ResultsCompared to non-Title X clinics, Title X clinics were more likely to offer reproductive life plan assessment (adjusted PR [aPR], 1.62; 95% CI, 1.42–1.84), body mass index screening for men (aPR, 1.10; 95% CI, 1.01–1.21), screening for sexually transmitted diseases (aPRs ranged from 1.21 to 1.37), and preconception health care for men (aPR, 1.10; 95% CI, 1.01–1.20). Title X clinics were less likely to offer infertility treatment (aPR, 0.55; 95% CI, 0.40–0.74) and primary care services (aPR, 0.74; 95% CI, 0.68–0.80) and were just as likely to offer basic infertility services, preconception health care services for women, natural family planning, and body mass index screening in women.ConclusionsThe availability of selected services related to achieving pregnancy differed by Title X status. A follow-up assessment after publication of national family planning recommendations is underway.     

Accessibility of Family Planning Services: Impact of Structural and Organizational Factors

Objectives: This study sought to determine whether selected structural and organizational characteristics of publicly available family planning facilities are associated with greater availability. Methods: A survey was sent to 726 publicly available family planning facilities in four states. These included local health departments, federally qualified health centers (FQHC), Planned Parenthood sites, hospital outpatient departments, and freestanding women’s health centers. Usable responses were obtained from 526 sites for a response rate of 72.5%. Availability variables included the provision of primary care services; the contraceptives offered; professional staffing; scheduling, waiting time, and transportation; and cultural congruence and competency. The structural and organizational variables were state, type of organization, and funding source. Results: Some states were more likely to offer emergency contraception while others were more likely to have weekend hours. FQHCs were most likely to provide primary care and Planned Parenthood sites most likely to offer emergency contraception. Title X funding was associated with increased likelihood of providing emergency contraception and staffing by midlevel practitioners and registered nurses. Conclusions: This study found that availability varied by structural and organizational variables, many of which are determined by federal and state policies. Revising some of these policies might increase utilization of family planning facilities.     

Physician perspectives on routine pregnancy intention screening and counseling in primary care

ObjectivesTo assess factors associated with routine pregnancy intention screening by primary care physicians and their support for such an initiative.Study designWe conducted a cross-sectional survey study of 443 primary care physicians in New York State. We performed multivariable logistic regression analyses of physician support for routine pregnancy intention screening and implementation of screening in the last year. Predictors included in the models were physician age, sex, specialty, clinic setting, and, for the outcome of support for screening, experience with screening in the last year.ResultsIn this convenience sample, the vast majority of respondents from all specialties (88%) felt pregnancy intention screening should be routinely included in primary care, with 48% reporting that they routinely perform such screening. The preferred wording for this question was one which assessed reproductive health service needs. In multivariable analyses, internal medicine physicians were less likely than family medicine physicians to have provided routine pregnancy intention screening (aOR = 0.15, 95% CI 0.09, 0.25). Only 8% of the sample reported they required more training to implement pregnancy intention screening, but more reported needing training prior to contraceptive provision (17%), contraceptive counseling (16%), and preconception care (15%). More internal medicine and other types of doctors cited a need for this additional training than family medicine physicians.ConclusionsMost responding primary care physicians supported routine integration of pregnancy intention screening. Incorporating additional training, especially for internal medicine physicians, in contraception and preconception care counseling is key to ensuring success.Implications statementResponding primary care physicians supported routine inclusion of reproductive health needs assessment in primary care. Primary care may become increasingly important for ensuring access to a full range of reproductive health services. Providing necessary training, especially for internal medicine physicians, is needed prior to routine inclusion.     

Reproductive Life Plan Counseling and Effective Contraceptive Use among Urban Women Utilizing Title X Services

BackgroundAlthough the Centers for Disease Control and Prevention and the U.S. Office of Population Affairs recommend inclusion of reproductive life plan counseling (RLPC) in all well-woman health care visits, no studies have examined the effect of RLPC sessions on the decision to use effective contraception at publicly funded family planning sites. RLPC could be a particularly impactful intervention for disadvantaged social groups who are less likely to use the most effective contraceptive methods.MethodsUsing data from 771 nonpregnant, non–pregnancy-seeking women receiving gynecological services in the Cincinnati—Hamilton County Reproductive Health and Wellness Program, multinomial logistic regression models compared users of nonmedical/no method with users of 1) the pill, patch, or ring, 2) depot medroxyprogesterone acetate, and 3) long-acting reversible contraception (LARC). The effect of RLPC on the use of each form of contraception, and whether it mediated the effect of race/ethnicity and education on contraceptive use, was examined while controlling for age, insurance status, and birth history. The interaction between RLPC and race/ethnicity and the interaction between RLPC and educational attainment was also assessed.FindingsRLPC was not associated with contraceptive use. The data suggested that RLPC may increase LARC use over nonmedical/no method use. RLPC did not mediate or moderate the effect of race/ethnicity or educational attainment on contraceptive use in any comparison.ConclusionsIn this system of publicly funded family planning clinics, RLPC seems not to encourage effective method use, providing no support for the efficacy of the RLPC intervention. The results suggest that this intervention requires further development and evaluation.     

Contraception and abortion coverage: what do primary care physicians think?

BackgroundInsurance coverage for family planning services has been a highly controversial element of the US health care reform debate. Whether primary care providers (PCPs) support public and private health insurance coverage for family planning services is unknown.Study DesignPCPs in three states were surveyed regarding their opinions on health plan coverage and tax dollar use for contraception and abortion services.ResultsAlmost all PCPs supported health plan coverage for contraception (96%) and use of tax dollars to cover contraception for low-income women (94%). A smaller majority supported health plan coverage for abortions (61%) and use of tax dollars to cover abortions for low-income women (63%). In adjusted models, support of health plan coverage for abortions was associated with female gender and internal medicine specialty, and support of using tax dollars for abortions for low-income women was associated with older age and internal medicine specialty.ConclusionThe majority of PCPs support health insurance coverage of contraception and abortion, as well as tax dollar subsidization of contraception and abortion services for low-income women.     

The effect of a no-cost contraceptive initiative on method selection by women with housing insecurity

ObjectivesTo compare the sociodemographic characteristics of participants in a contraceptive initiative by housing security and determine the association between housing insecurity on contraceptive method selection before and after the removal of cost.Study designThis cross-sectional assessment includes 4,327 reproductive-aged participants in the HER Salt Lake Contraceptive Initiative who sought new contraceptive services and reported housing status at enrollment. HER Salt Lake prospectively explored the impact of improved contraceptive access on socioeconomic outcomes in Salt Lake County (USA). For six months (September 2015–March 2016) we collected control data, which included clinic standard-of-care cost-sharing. The intervention started March 2016, and provided no-cost contraception services and unlimited opportunities for method switching over the subsequent three years.ResultsThere were 964 (22%) housing-insecure participants. Compared to those with stable housing, housing-insecure individuals more commonly identified as a sexual minority, received public assistance and lacked health insurance. Housing-insecure women preferentially selected long-acting reversible contraception during the control period (aOR 1.60; 95%CI 1.01–2.56), but method selection equalized across housing status during the intervention.ConclusionsWhen cost is not a barrier, all women desire a comprehensive selection of contraceptive methods, regardless of housing security. Contraceptive clients in this vulnerable population need interventions which address access barriers to all methods to support reproductive planning.ImplicationsUnintended pregnancy during housing insecurity may result in homelessness. This study found housing-insecure women desire access to all contraceptive methods, not just long acting reversible contraception. Integration of comprehensive family planning initiatives into efforts to address homelessness is essential to support this vulnerable population in their reproductive planning.     

Family Planning Services: An Essential Component of Preconception Care

Family planning services are necessary for the widespread adoption of preconception care for two reasons. First, preconception care is more likely if pregnancies are planned, and family planning services encourage pregnancy planning. Second, family planning services usually include counseling, and counseling provides an opportunity to discuss the advantages of preconception care. However, the potential of family planning services to promote preconception care is limited by underutilization of these services and inadequate attention to preconception care during family planning visits. This article suggests ways to reduce these problems.

     

Factors associated with provision of depot medroxyprogesterone acetate to adolescents by US health care providers

ObjectiveIdentify factors associated with healthcare providers' frequency of depot medroxyprogesterone acetate (DMPA) provision to adolescents.Study designWe analyzed data from surveys mailed to a nationally representative sample of public-sector providers and office-based physicians (n=1984). We estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of factors associated with frequent DMPA provision to adolescents in the past year.ResultsAlthough most providers (>95%) considered DMPA safe for adolescents, fewer reported frequent provision (89% of public-sector providers; 64% of office-based physicians). Among public-sector providers, factors associated with lower odds of frequent provision included working in settings without Title X funding (aOR 0.44, 95% CI 0.30–0.64), reporting primary care as their primary clinical focus versus reproductive or adolescent health (aOR 0.42, 95% CI 0.28–0.61), and providing fewer patients with family planning services. Among office-based physicians, factors associated with lower odds of frequent provision included specializing in obstetrics/gynecology (aOR 0.50, 95% CI 0.27–0.91) and family medicine (aOR 0.21, 95% CI 0.09–0.47) versus adolescent medicine, completing training ≥15 versus <5 years ago (aOR 0.27, 95% CI 0.09–0.83), and reporting that 0–24% of patients pay with Medicaid or other government healthcare assistance versus ≥50% (aOR 0.23, 95% CI 0.09–0.61). The reason most commonly reported by providers for infrequent DMPA provision was patient preference for another method.ConclusionsWhile most providers reported frequently providing DMPA to adolescents, training on evidence-based recommendations for contraception, focused on subgroups of providers with lower odds of frequent DMPA provision, may increase adolescents' access to contraception.ImplicationsAlthough >95% of providers considered depot medroxyprogesterone (DMPA) a safe contraceptive for adolescents, only 89% of public-sector providers and 64% of office-based physicians reported frequently providing DMPA to adolescents. Provider training on evidence-based recommendations for contraception counseling and provision may increase adolescents' access to DMPA and all methods of contraception.     

基层计生干部对计划生育优质服务和避孕方法知情选择认知水平调查及影响因素分析

目的:了解基层计生干部对计划生育优质服务和避孕方法知情选择的认知水平,同时分析其影响因素。方法:调查76名基层计生干部对计划生育优质服务、避孕方法知情选择的认知情况及对实行避孕方法知情选择的态度和建议。结果:基层计生干部对计划生育优质服务“六要素”的认知及格率为75·4%,但无1人能全部正确回答,其中年龄、职业级别和文化程度影响及格率;对于避孕方法知情选择57·89%的基层计生干部是通过上级领导会议传达了解,影响因素为职业级别、有无专业技术职称。结论:当前政府相关部门应重视对基层计生干部的培训,提高其业务素质,保证计划生育工作的顺利健康开展。     

Reaching Adolescent Girls and Young Women With HIV Self-Testing and Contraception at Girl-Friendly Drug Shops: A Randomized Trial in Tanzania

PurposeWe hypothesized that an intervention designed to create girl-friendly drug shops would increase access to sexual and reproductive health products and services among adolescent girls and young women (AGYW) (ages 15–24 years) in Tanzania.MethodsWe conducted a four-month randomized trial at 20 drug shops in Shinyanga, Tanzania from August–December 2019 to determine if the Malkia Klabu (“Queen Club”) intervention increased AGYW patronage and the provision of HIV self-testing (HIVST), contraception, and health facility referrals to AGYW (primary outcomes). Drug shops were randomized 1:1 to the intervention or comparison arm. All shops were provided with OraQuick HIVST kits to give to AGYW for free. Intervention shops implemented Malkia Klabu, a loyalty program for AGYW created using human-centered design through which AGYW could also access free contraception. We compared outcomes in intention-to-treat analyses using shop observations and shopkeeper records.ResultsBy endline, shops implementing Malkia Klabu had higher AGYW patronage than comparison shops (rate ratio: 4.4; 95% confidence interval: 2.0, 9.8). Intervention shops distributed more HIVST kits (median per shop: 130.5 vs. 58.5, P = .02) and contraceptives (325.5 vs. 7.0, P < .01) to AGYW and provided more referrals for HIV, family planning, or pregnancy services combined (3.5 vs. 0.5, P = .02) than comparison shops.DiscussionThe Malkia Klabu intervention increased AGYW patronage and the provision of HIVST kits, contraception, and referrals to AGYW at drug shops, despite HIVST kits being freely available at all participating shops. Enhancing drug shops with girl-friendly services may be an effective strategy to reach AGYW with sexual and reproductive health services.     

人工流产后计划生育服务干预效果观察

目的探究人工流产（人流）后对患者进行计划生育服务干预所产生的临床效果。方法对2011年5月-2013年5月山东省枣庄市峄城区计划生育服务站门诊及住院部收治的76例行人流手术者为研究对象,对其进行流产后计划生育服务干预,分析比较干预前后患者对计划生育知识的掌握情况。结果干预前患者对计划生育服务知识总体掌握率为23.68%,干预后提升到85.53%,干预前随访1年后患者计划生育服务知识总体掌握率比较（χ2=58.2432,P=0.0000）,患者避孕无措施的比例减少（χ2=4.6093,P=0.0318）,高效避孕方法（干预前42.11%、干预后92.11%）和低效避孕方法的整体掌握情况均提高（干预前43.42%、干预后68.42%）,差异均具有统计学意义（χ2=42.7537,P=0.0000;χ2=9.5717,P=0.0020）。结论对人流后的患者行计划生育服务干预,提高了患者对计划生育知识的掌握,促进患者生殖健康水平的提高,值得在临床上运用。     

The process of opting for female permanent contraception: A qualitative study of women’s experiences in Sweden

ObjectivesWe aimed to explore Swedish women's decision-making experiences regarding permanent contraception.Study designIn this study, we included 17 women aged 30–48 who were scheduled to undergo female permanent contraceptive procedures. We conducted semistructured interviews using two broad open-ended questions. We analyzed these data using systematic text condensation based on the principles of psychological phenomenological analysis.ResultsThe interviewees experienced no counseling or support from health care workers regarding permanent contraception until they specifically asked for it. Participants reported that they themselves place the responsibility of permanent contraception solely on women. Consequently, our participants described feeling hesitancy and ambivalence in the process of deciding to have the procedure. Once the decision was made and the women were on the waiting lists for surgery, they experienced relief and empowerment.ConclusionsOur findings suggest that health care providers in Sweden miss opportunities to support patient-centered decision-making regarding permanent contraception. This study indicates that women make deliberate and considered decisions regarding permanent contraception and are best positioned to know when the procedure should take place in their reproductive lives.Implication statementsHealth care professionals should discuss permanent contraception as an option with all women desiring contraception to allow them to decide if that method is right for them.     

Specialized Family Planning Clinics in the United States: Why Women Choose Them and Their Role in Meeting Women's Health Care Needs

BackgroundPublicly funded family planning clinics provide contraceptive care to millions of poor and low-income women every year. To inform the design of services that will best meet the contraceptive and reproductive health needs of women, we conducted a targeted survey of family planning clinic clients, asking women about services received in the past year and about their reasons for visiting a specialized family planning clinic.MethodsWe surveyed 2,094 women receiving services from 22 family planning clinics in 13 states; all sites included in the survey were clinics that specialize in contraceptive and reproductive health services and were located in communities with comprehensive primary care providers.ResultsSix in 10 (59%) respondents had made a health care visit to another provider in the past year, but chose the family planning clinic for contraceptive care. Four in 10 (41%) respondents relied on the family planning clinic as their only recent source for health care. The four most common reasons for choosing a specialized family planning clinic, reported by at least 80% of respondents, were respectful staff, confidential care, free or low-cost services, and staff who are knowledgeable about women's health.ConclusionsSpecialized family planning clinics play an important role as part of the health care safety net in the United States. Collaborations between such clinics and comprehensive primary care providers, such as federally qualified health centers, may be one model for ensuring women on-going access to the full range of care they need.     

History of the Chinese Family Planning program: 1970-2010

BackgroundChina launched a nationwide family planning program offering birth control methods and family planning services in the 1970s. Promotion of the widespread use of long-term contraceptive methods has been one of the program's core strategies. This paper reviews the history of China's Family Planning Program at the national level from 1970 to 2010. Special attention is paid to the history of contraception policy.Study DesignThis study provides an overview of the last four decades of the Chinese Family Planning Program. Programmatic goals are highlighted during different time periods, with special attention being paid to the role of contraceptive use and the history of contraceptive policy.ResultsThe Chinese Family Planning Program has experienced several transitions. It has evolved from the 1970s period of moderate policy, represented by wan, xi, shao (late marriage and childbearing, birth spacing and limited fertility), through the strict one-child policy of 1979 to the early 1990s. From the mid-1990s to the present, a relatively lenient policy has been in force, characterized by client-centered informed choice.ConclusionsThe success of the Chinese Family Planning Program has long been heavily dependent on policies advocated by the central government, including programs promoting contraception to reduce fertility rates. The Program also depended on a logistical support system, including organizational safeguards and free provision of contraception and family planning services.     

The Organization and Delivery of Family Planning Services in Community Health Centers

BackgroundFamily planning and related reproductive health services are essential primary care services for women. Access is limited for women with low incomes and those living in medically underserved areas. Little information is available on how federally funded health centers organize and provide family planning services.MethodsThis was a mixed methods study of the organization and delivery of family planning services in federally funded health centers across the United States. A national survey was developed and administered (n = 423) and in-depth case studies were conducted of nine health centers to obtain detailed information on their approach to family planning.FindingsStudy findings indicate that health centers utilize a variety of organizational models and staffing arrangements to deliver family planning services. Health centers' family planning offerings are organized in one of two ways, either a separate service with specific providers and clinic times or fully integrated with primary care. Health centers experience difficulties in providing a full range of family planning services.Major ChallengesMajor challenges include funding limitations; hiring obstetricians/gynecologists, counselors, and advanced practice clinicians; and connecting patients to specialized services not offered by the health center.ConclusionsHealth centers play an integral role in delivering primary care and family planning services to women in medically underserved communities. Improving the accessibility and comprehensiveness of family planning services will require a combination of additional direct funding, technical assistance, and policies that emphasize how health centers can incorporate quality family planning as a fundamental element of primary care.