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

Policy impacts on contraceptive access in the United States: a scoping review

Contraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.

Policy impacts on contraceptive access in the United States: a scoping review

Contraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.

Marshallese Mothers' and Marshallese Maternal Healthcare Providers' Perspectives on Contraceptive Use and Reproductive Life Planning Practices and Influences

Pacific Islander communities experience significant maternal and infant health disparities including high maternal and infant mortality. Contraception and reproductive life planning prevent approximately one-third of pregnancy-related deaths and neonatal deaths. We report the results of formative research devoted to understanding Marshallese mothers' as well as their maternal healthcare providers' practices and influences related to contraceptive use and reproductive life planning. This study used an exploratory, descriptive qualitative design to explore Marshallese mothers' and maternal healthcare providers' practices and influences of contraception use and reproductive life planning. Twenty participants were enrolled in the study, 15 Marshallese mothers and five Marshallese maternal healthcare providers. For the Marshallese mothers, two themes emerged: (1) Reproductive Life Planning Practices and Information; and (2) Reproductive Life Planning Influences. For the Marshallese maternal healthcare providers, two themes emerged: (1) Reproductive Life Planning Practices; and (2) Reproductive Life Planning Influences. This is the first study to document Marshallese mothers' and maternal healthcare providers' practices and influences with contraceptive use and reproductive life planning. Study results will inform the development of a culturally-adapted contraception and reproductive life planning tool with an educational program for Marshallese family units and maternal healthcare providers serving Marshallese women.

Association Between Publicly Funded Contraceptive Services and the Abortion Rate in Texas, 2010-2015

OBJECTIVE

To evaluate how the availability of contraceptive services was associated with a change in the abortion rate before and after Texas' legislative changes to the family planning budget in 2011 and abortion access in 2013.

METHODS

In this cross-sectional study, we obtained 2010 and 2015 data on contraceptive provision (number of publicly funded clinics and number of contraceptive clients served per 1,000 reproductive-aged women) from the Guttmacher Institute and county-level abortion data from the Texas Department of State Health Services. We categorized counties as having an abortion rate that increased or declined less than the national rate between 2010 and 2015 ( low-decline counties ) compared with those having an abortion rate that declined equal to or greater than the national rate between 2010 and 2015 ( high-decline counties ). We evaluated differences in contraceptive provision between high-decline and low-decline counties and evaluated county characteristics (racial and ethnic composition, unemployment, poverty, uninsured, education, distance to an abortion clinic, deliveries covered by Medicaid, and Catholic hospital marketplace dominance) as potential confounders.

RESULTS

Of 157 counties that had at least one contraceptive clinic in either 2010 or 2015, 49 were low-decline counties and 108 were high-decline counties. Although the total number of publicly funded family planning clinics increased by 10.8%, there was a 4.7% decrease in the total number of contraceptive clients served statewide. Compared with low-decline counties, high-decline counties had a higher median number of contraceptive clients served per 1,000 women aged 18-44 years (31.9 vs 60.7, P <.05) in 2015. Between 2010 and 2015, the abortion rate decreased 19.7% for each 1.0% increase in contraceptive clients served.

CONCLUSION

Texas counties with higher abortion-rate declines had more publicly funded contraceptive clinics and served more contraceptive clients than counties with lower declines, which may indicate the importance of greater access to publicly funded contraceptive services.

Association of Title X clinic status with receipt of person-centered contraceptive counseling: a population-based study

OBJECTIVE

To describe receipt of person-centered contraceptive counseling among reproductive-aged women in the United States who sought contraceptive care at Title X clinics, non-Title X public clinics, and private clinics.

STUDY DESIGN

We conducted a secondary analysis of the 2017-2019 wave of the National Survey of Family Growth (NSFG). The sample included female respondents ages 15-49 who received contraceptive services in the past year and completed the Person-Centered Contraceptive Counseling (PCCC) measure, a quality metric evaluating interpersonal quality of the care received. We used multivariable logistic regression to estimate the predicted probability of receiving person-centered contraceptive counseling by source of care, adjusted for individual-level characteristics.

RESULTS

Of 2,225 (weighted N=26,599,620) eligible respondents, 6.9% received care at a Title X clinic, 8.2% at a non-Title X public clinic, and 84.9% at a private clinic. The adjusted predicted probability of receiving person-centered contraceptive counseling among respondents attending private clinics was 50.6% (95% CI 46.3-54.8%) compared with 51.3% (95% CI 40.4-62.3%) at Title X clinics and 52.4% (95% CI 44.0-60.7%) at other public clinics. Respondents with incomes ≥300% above the federal poverty level (FPL) had higher odds of reporting receipt of person-centered counseling compared to those with incomes below 100% of the FPL (aOR = 2.12; 95% CI 1.47-3.06). Non-Latina Black respondents had lower odds of receiving person-centered contraceptive counseling (aOR = 0.69; 95% CI 0.51-0.94), compared to non-Latina white respondents.

CONCLUSION

Title X clinics perform as well as the private sector in delivering person-centered contraceptive counseling.

IMPLICATIONS

Title X clinics provide quality person-centered contraceptive counseling on par with the private sector, despite serving populations that are often less likely to report high quality care. Broad implementation of the PCCC measure will permit tracking person-centered contraceptive care across diverse practice settings and populations.

Title X Improved Access To Most Effective And Moderately Effective Contraception In US Safety-Net Clinics, 2016-18

Community health centers are a crucial source of health care for reproductive-age women. Some community health centers receive funding from the federal Title X program, which provides funding for family planning services for low-income women. We describe the provision of the most effective (intrauterine devices and implants) and moderately effective (short-acting hormonal methods) contraceptive methods in a large network of 384 community health center clinics across twenty states in 2016-18. Title X clinics provided more most and moderately effective contraception at all time points and for all age groups (adolescent, young adult, and adult). They provided 52 percent more of the most effective contraceptives to women at risk for pregnancy than clinics not funded by Title X. This finding was especially notable for adolescents (58 percent more). Title X clinics play a key role in access to effective contraception across the US safety net. Strengthening the Title X program should continue to be a policy priority for public health for the Biden-Harris administration.

Geographic differences in contraception provision and utilization among federally funded family planning clinics in South Carolina and Alabama

PURPOSE

Access to the full range of contraceptive options is essential to providing patient-centered reproductive health care. Women living in rural areas often experience more barriers to contraceptive care than women living in urban areas. Therefore, federally funded family planning clinics are important for ensuring women have access to contraceptive care, especially in rural areas. This study examines contraceptive provision, factors supporting contraceptive provision, and contraceptive utilization among federally funded family planning clinics in 2 Southern states.

METHODS

All health department and Federally Qualified Health Center clinics in Alabama and South Carolina that offer contraceptive services were surveyed in 2017-2018. Based on these surveys, we examined differences between rural and urban clinics in the following areas: clinic characteristics, services offered, staffing, staff training, policies, patient characteristics, contraceptive provision, and contraceptive utilization. Differences were assessed using Chi-square tests of independence for categorical variables and independent t-tests for continuous variables.

FINDINGS

Urban clinics had more staff on average than rural clinics, but rural clinics reported greater ease in recruiting and retaining family planning providers. Patient characteristics did not significantly vary between rural and urban clinics. While no significant differences were observed in the provision of long-acting reversible contraceptives (LARCs) overall, a greater proportion of patients in urban clinics utilized LARCs.

CONCLUSIONS

While provision of most contraceptives is similar between rural and urban federally funded family planning clinics, important differences in other factors continue to result in women who receive care in rural clinics being less likely to choose LARC methods.

Trends in initiation of hormonal contraceptive methods among teenagers born between 1989 and 1997 in Norway and the United States

OBJECTIVE

To assess initiation of hormonal contraception among women aged 15-19 in the US and Norway by birth cohort.

STUDY DESIGN

We used population-based survey (US) and administrative (Norway) data to estimate the cumulative probability of age at first use of hormonal contraception for female residents born between 1989 and 1997 in 3-year birth cohorts. Differences between countries were assessed using confidence intervals, and differences between birth cohorts were assessed using survival analysis.

RESULTS

At age 15, first use of any hormonal method was higher among US respondents (16%-17% US vs 10%-13% Norway), whereas for ages 16 to 19 use was higher among Norwegian women (by age 19, 60%-64% US vs 76%-78% Norway). Similar patterns were observed for pill use; however, depot medroxyprogesterone acetate (DMPA), implant, and intrauterine device (IUD) use tended to be higher among US women. In both countries, cumulative first use of the pill, patch, ring, and DMPA declined across birth cohorts while first use of implants and IUDs increased.

CONCLUSION

Age at initiation and type of first hormonal method use differed between US and Norwegian teenagers. These differences may contribute to the lower teen birth rate in Norway.

Contraceptive Method Use by Rural-Urban Residence among Women and Men in the United States, 2006 to 2017

PURPOSE

Policy and reproductive health practice changes in the past decade have affected use of different contraceptive methods, but no study has assessed contraceptive method use over this time by rural-urban residence in the United States.

METHODS

We used female and male respondent data (2006-2017) from the National Survey of Family Growth (n = 29,133 women and n = 24,364 men) to estimate contraceptive method use by rural-urban residence over time and contraceptive method use by age, marital status, and parity/number of children.

RESULTS

From 2006-2010 to 2013-2017, among urban women, we found increased use of two or more methods (11% to 14%); increased use of intrauterine devices (5% to 11%), implants (0 to 2%), and withdrawal (5 to 8%); and decreased use of sterilization (28% to 22%) and pills (26% to 22%). Among rural women, we found increased use of intrauterine devices (5% to 9%) and implants (1% to 5%). We found increased withdrawal use for urban men, but otherwise no differences among men across time. In data pooled across all survey periods (2006-2017), contraceptive method use varied by rural-urban residence across age, marital status, and parity/number of children.

CONCLUSIONS

In a nationally representative sample of reproductive age women and men, we found rural-urban differences in contraceptive method use from 2006-2010 to 2013-2017. Describing contraceptive use differences by rural-urban residence is necessary for tailoring reproductive health services to populations appropriately.

Understanding the extent of contraceptive non-use among women at risk of unintended pregnancy, National Survey of Family Growth 2011-2017

Objective

To describe characteristics of U.S. contraceptive non-users to inform tailored contraceptive access initiatives.

Study design

We used National Survey of Family Growth data from 2011 to 2017 to identify characteristics of contraceptive non-users compared to other women ages 15–44 at risk for unintended pregnancy. We also examined reasons for not using contraception by when non-users expected their next birth. We calculated unadjusted and adjusted prevalence ratios using two definitions of contraceptive non-use: (1) contraceptive non-use during the interview month, and (2) a more refined definition based on contraception use during the most recent month of sexual intercourse and expectation of timing of next birth. We considered p-values < 0.05 statistically significant.

Results

Approximately 20% (n = 2844) of 12,071 women at risk of unintended pregnancy were classified as standard contraceptive non-users. After adjusting for all other variables, non-users were more likely to be low-income, uninsured, never married, expect a birth within 2 years, and have zero or one parity. The top reasons for contraceptive non-use were not minding if they got pregnant (22.6%), worried about contraceptive side effects (21.0%), and not thinking they could get pregnant (17.6%). After applying the more refined non-user definition, we identified 5.7% (n = 721) of women as non-users; expecting a birth within 2–5 years and having a parity of one were associated with non-use after adjustment of all other factors.

Conclusion

Our more refined definition of non-users could be used in future studies examining the causes of unintended pregnancy and to inform programmatic interventions to reduce unintended pregnancy.

Implications

Describing contraceptive non-users and reasons for contraceptive non-use could help us better understand reasons for unintended pregnancy and inform tailored contraceptive access initiatives.