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

What's Behind the Dramatic Pre-2020 Declines in Hispanic/Latina Adolescent Childbearing? Decomposing Change by Age, Origin, and Nativity

PURPOSE

To assess whether the large declines in adolescent childbearing among Hispanic adolescents over the period 2000-2019 have been driven by co-occurring changes in the composition of the Hispanic population and, if so, whether they have done so differentially by Hispanic subgroup.

METHODS

We use birth counts from the United States vital statistics system and population denominators from the United States decennial census long form 5-percent Public Use Microdata and the American Community Survey to conduct a decomposition analysis apportioning observed declines in Hispanic adolescent childbearing to: (1) compositional shifts in nativity, age, and region-of-origin and (2) subgroup changes in childbearing rates.

RESULTS

The Hispanic adolescent fertility rate fell by over 71% from 2000 to 2019, with Mexican-Origin, United States-born, and younger adolescents exhibiting the steepest declines (79%, 70%, and 80% declines, respectively). Results from the decomposition analysis show that almost 90% of the decline is due to within-group rate change, with some variability by subgroup and by decade. Only 10% of the decline was due to compositional changes, with shifts in nativity driving much of the effect.

DISCUSSION

Declines in Hispanic adolescent childbearing over the last decades have occurred in spite of substantial shifts in the composition of the Hispanic population, not because of them. These findings set the stage for a more detailed examination of the drivers of change in sexual activity, contraceptive use, and abortion, all of which are proximate determinants of adolescent pregnancy and childbearing. Additionally, a focus on more distal factors is needed, including the role that changing political, societal, and economic conditions in the United States have for early fertility patterns.

Contraceptive Method Use Among a Population-Based Cohort During the South Carolina Choose Well Initiative

Importance

Evaluating the impact of statewide contraceptive access initiatives is necessary for informing health policy and practice.

Objective

To examine changes in contraceptive method use among a cohort of women of reproductive age in South Carolina during the Choose Well contraceptive access initiative.

Design, Setting, and Participants

In this cohort study, baseline data from the initial Statewide Survey of Women administered from October 1, 2017, to April 30, 2018, to a probability-based sample of women of reproductive age in South Carolina and a peer state (Alabama) were linked with 3 follow-up surveys given in 2019, 2020, and 2021. Responses about contraception use from the initial survey were compared with responses across follow-up surveys using the regression-based differences-in-differences method. Data analysis was performed from October 2023 to February 2024.

Exposure

The South Carolina Choose Well contraceptive access initiative seeks to fill contraceptive access gaps and increase provision of a full range of contraceptive methods through engagement with a wide range of health care organizations across the state.

Main Outcomes and Measures

Changes in contraceptive method use, including long-acting reversible contraception (LARC), intrauterine devices (IUDs), implants, short-acting hormonal injection, and barrier or other methods between the baseline survey (2017-2018) and 3 subsequent surveys (2019-2021).

Results

A total of 1344 female participants (mean [SD] age, 34 [7] years) completed the first survey (667 in Alabama and 677 in South Carolina). Use of LARC significantly increased in South Carolina (119 [17.6%] to 138 [21.1%]) compared with Alabama (120 [18.0%] to 116 [18.1%]; P = .004). Use of IUDs increased in South Carolina (95 [14.0%] to 114 [17.4%]) compared with Alabama (92 [13.8%] to 102 [15.9%]; P = .003). These associations persisted in the adjusted analysis, with a significant increase in the odds of LARC (adjusted odds ratio, 1.24; 95% CI, 1.06-1.44) and IUD (adjusted odds ratio, 1.19; 95% CI, 1.06-1.32) use at follow-up in South Carolina compared with Alabama.

Conclusions and Relevance

In this cohort study of 1344 participants, increases in the use of IUDs in South Carolina were noted after the implementation of the South Carolina Choose Well initiative that were not observed in a peer state with no intervention. Our findings may provide support in favor of statewide contraceptive access initiatives and their role in promoting access to reproductive health services.

Contraceptive counseling, method satisfaction, and planned method continuation among women in the U.S. southeast

OBJECTIVES

We used the validated Person-Centered Contraceptive Counseling (PCCC) scale to examine experiences with counseling and associations between counseling quality, method satisfaction, and planned method continuation at the population level in two southeastern states.

STUDY DESIGN

We used data from the Statewide Survey of Women, a probability-based sample of reproductive-aged women in Alabama and South Carolina in 2017/18. We included women using a contraceptive method and reporting a contraceptive visit in the past year (n = 1265). Respondents rated their most recent provider experience across four PCCC items. Regression analyses examined relationships between counseling quality and outcomes of interest, and path analysis examined the extent to which method satisfaction mediated the effects of counseling quality on planned continuation.

RESULTS

Over half of participants (54%) reported optimal contraceptive counseling. Optimal counseling was associated with method satisfaction (aPR = 1.16; 95% confidence interval (CI) = 1.04-1.29) in adjusted models. Optimal counseling was marginally associated with planned discontinuation in the bivariate analysis but was attenuated in the adjusted model (aPR = 1.07; 95% CI = 0.98-1.18). In the path analysis, counseling quality influenced method satisfaction (0.143 (0.045), p = 0.001) which influenced planned continuation, controlling for PCCC (0.74 (0.07), p < 0.001). The total indirect effect of counseling quality on planned continuation was significant (0.106 (0.03), p = 0.001), and a residual direct effect from counseling quality to planned continuation was noted (0.106 (0.03), p = 0.001).

CONCLUSIONS

Counseling quality is independently associated with method satisfaction at the population level. The effect of counseling on planned continuation is partially mediated by method satisfaction.

IMPLICATIONS

Interventions to support person-centered contraceptive counseling promise to improve quality of care, patient experience with care, and reproductive outcomes.

Early national trends in non-abortion reproductive care access after Roe

Background

Roe was overturned in 2022. No peer-reviewed evidence exists for the indirect spillover effects of overturning Roe on non-abortion reproductive care access for diverse patient populations.

Methods

National data were from 2013-2023 HHS Title X Directory, 2013-2020 CDC Artificial Reproductive Technologies (ART) Surveillance and 2021-2023 manual collection, and Guttmacher Institute. Outcome measures included numbers of ART clinics and Title X entities. Title X entities are those that receive federal funds to establish and operate voluntary family planning projects, especially for low-income patients. We reported pre-and post-Roe changes, associations between changes in measures and abortions, and characteristics of changed measures by region and political geography.

Results

Post-Roe America witnessed national declines of 1.03% in ART clinics and 18.34% in Title X entities, and average state decreases of 0.08 ART clinics (p < 0.05) and 18 Title X entities (p < 0.001). State-level ART clinic closures and abortion reductions had little association except for Texas, Oklahoma, Arizona, New York, and California. Plummets in Title X entities and abortions were positively associated: Reducing 100 abortions was associated with defunding two Title X entities (p < 0.05). The South experienced the largest losses of both, while 83.39% of lost Title X entities were in states that voted Republican in the 2020 presidential election, disproportionate to the 49.02% of states that voted Republican and the 42.52% of US population residing in these states.

Conclusion

We provide one of the first few evidence of spillover impacts of overturning Roe on non-abortion care access for diverse populations: low-income men and women, single parents by choice, and biologically and socially infertile patients. Early evidence warns of worsening challenges of inequities and calls for immediate policy actions.

Contraception Use by Title X Clients and Clients of Other Providers, 2015-2019

INTRODUCTION

Title X clinics provide access to a wide range of contraceptive options for individuals of all income levels and documentation statuses. As Title X continues to face political uncertainties, it is important to provide up-to-date information about its clients' use of contraception. This study used recent nationally representative data to compare contraception received by Title X clients with that received by clients of other providers.

METHODS

This article draws on 2015-2017 and 2017-2019 waves of the National Survey of Family Growth. The sample was restricted to 15- to 44-year-old women needing contraception. Logistic regressions estimated associations between receiving services at Title X clinics versus at other providers (including private) and use of a range of contraceptive options, as well as number of months' supply for those using oral contraceptives.

RESULTS

In 2015-2017, Title X was associated with using any contraception (adjusted odds ratio [AOR], 4.11; p = .004). In both waves, Title X clients were more likely to use long-acting reversible contraceptives (AOR, 1.78 in 2015-2017 [p = .023] and AOR, 2.59 in 2017-2019 [p = .003]) and hormonal methods other than oral contraceptives (AOR, 2.31 in 2015-2017 [p = .007] and AOR, 3.04 in 2017-2019 [p = .001]). In both waves, Title X clients using oral contraceptives were also more likely than non-Title X clients to receive more than a 3-month supply (AOR, 3.54 in 2015-2017 [p = .008] and AOR, 2.61 in 2017-2019 [p = .043]). Title X was not associated in either wave with use of barrier or time-based methods, such as periodic abstinence or withdrawal.

CONCLUSIONS

Patterns of contraceptive use by Title X clients compared with those of clients of other providers indicate that the Title X program has allowed access to a wide range of contraceptive methods. Ongoing research is necessary to see whether these patterns change over time.

Structural barriers to health care as risk factors for preterm and small-for-gestational-age birth among US-born Black and White mothers

We develop county-level measures of structural and institutional barriers to care, and test associations between these barriers and birth outcomes for US-born Black and White mothers using national birth records for 2014-2017. Results indicate elevated odds of greater preterm birth severity for Black mothers in counties with higher uninsurance rates among Black adults, fewer Black physicians per Black residents, and fewer publicly-funded contraceptive services. Most structural barriers were not associated with small-for-gestational-age birth, and barriers defined for Black residents were not associated with birth outcomes for White mothers, with the exception of Black uninsurance rate. Structural determinants of care may influence preterm birth risk for Black Americans.

Contraception use and satisfaction among mothers with low income: Evidence from the Baby's First Years study

OBJECTIVES

Low income can lead to limited choice of and access to contraception. We examine whether an unconditional cash transfer (UCT) impacts contraceptive use, including increased satisfaction with and reduced barriers to preferred methods, for individuals with low income.

STUDY DESIGN

Baby's First Years is a randomized control study of a monthly UCT to families with low incomes. The study enrolled 1000 mothers at the time of childbirth across four US sites in 2018-2019; 400 were randomized to receive a UCT of $333/mo and 600 were randomized to receive $20/mo for the first years of their child's life. We use intent-to-treat analyses to estimate the impact of the cash transfer on contraception use, satisfaction with contraception method, and barriers to using methods of choice.

RESULTS

Over 65% of mothers reported using some type of contraception, and three-quarters reported using the method of their choice. We find no impact of the UCT on mothers' choice of, satisfaction with, or barriers to contraception. However, the cash transfer was associated with trends toward using multiple methods and greater use of short-term hormonal methods.

CONCLUSIONS

We find high levels of satisfaction with current contraceptive use among mothers of young children with low income. Receipt of monthly UCTs did not impact contraception methods, perceived barriers to use, or satisfaction. Yet, 25% were not using the method of their choice, despite the provision of cash, indicating that this cash amount alone may not be sufficient to impact contraceptive use or increase satisfaction.

IMPLICATIONS

Satisfaction with contraception use among low-income populations may be higher than previously documented. Nevertheless, provision of modest financial resources alone may not sufficiently address access, availability, and satisfaction for individuals with low-incomes of childbearing age. This suggests the importance of exploring how other nonfinancial factors influence reproductive autonomy, including contraceptive use.

Impact of the Choose Well Contraceptive Access Initiative on Method Use Among Women Enrolled in South Carolina's Medicaid Program: A Mid-line Assessment

INTRODUCTION

A six-year statewide contraceptive access initiative focused on equitable access to contraception, removing cost barriers, capacity building and training, raising consumer awareness, and expanding contraceptive care at safety net clinics was implemented in South Carolina beginning in 2017. This study assessed changes in contraceptive method use among women enrolled in the South Carolina Medicaid program during the first three years of Choose Well.

METHODS

Contraception use among a retrospective cohort of women aged 15 to 45 enrolled in South Carolina Medicaid from 2012 to 2020 was examined. Interrupted time series regression analysis was used to assess changes in the use of intrauterine devices (IUDs) and contraceptive implants between 2012 and 2016 and 2017 and 2020. Analyses were conducted for all women and stratified by age groups.

RESULTS

Long-acting reversible contraception use increased from 8.5% during the pre-Choose Well period to 10.9% during the Choose Well period (p < .001), with IUD use increasing from 4.3% to 5.2% (p < .001) and implant use increasing from 4.6% to 6.0% (p < .001). The interrupted time series analysis found a significant positive change in the average level of monthly IUD use after Choose Well began (0.493 percentage points; 95% confidence interval, 0.311-0.675). The effect was stronger among women 20 to 25 years of age. Choose Well significantly increased the trend in IUD use among all women by a positive 0.013 percentage points (95% confidence interval, 0.006-0.020) per month beyond expected values.

CONCLUSIONS

At the mid-point of the Choose Well Evaluation, the use of IUD methods increased significantly beyond what would be expected had pre-Choose Well trends continued. This was particularly evident among women 20 to 25 years of age. These findings suggest that Choose Well succeeded in reducing barriers to the use of IUDs.

Contraceptive Method Switching and Long-Acting Reversible Contraception Removal in U.S. Safety Net Clinics, 2016-2021

OBJECTIVE

To describe patterns of contraceptive method switching and long-acting reversible contraception (LARC) removal in a large network of community health centers.

METHODS

We conducted a retrospective cohort study using individual-level electronic health record data from 489 clinics in 20 states from 2016 to 2021. We used logistic regression models, including individual-, clinic-, and state-level covariates, to calculate adjusted odds ratios and predicted probabilities of any observed contraceptive method switching and LARC removal among those with baseline incident LARC, both over 4-year time periods.

RESULTS

Among 151,786 patients with 513,753 contraceptive encounters, 22.1% switched to another method at least once over the 4-year observation period, and switching patterns were varied. In patients with baseline LARC, the adjusted predicted probability of switching was 19.0% (95% CI 18.0-20.0%) compared with patients with baseline moderately effective methods (16.2%, 95% CI 15.1-17.3%). The adjusted predicted probability of switching was highest among the youngest group (28.6%, 95% CI 25.8-31.6% in patients aged 12-14 years) and decreased in a dose-response relationship by age to 8.4% (95% CI 7.4-9.4%) among patients aged 45-49 years. Latina and Black race and ethnicity, public or no insurance, and baseline Title X clinic status were all associated with higher odds of switching at least once. Among baseline LARC users, 19.4% had a removal (to switch or discontinue) within 1 year and 30.1% within 4 years; 97.6% of clinics that provided LARC also had evidence of a removal.

CONCLUSION

Community health centers provide access to method switching and LARC removal. Contraceptive switching and LARC removal are common, and clinicians should normalize switching and LARC removal among patients.

Expanded Contraceptive Access Linked To Increase In College Completion Among Women In Colorado

Public subsidies for contraception are often justified by assertions regarding their benefits for women's lives, yet there is limited contemporary evidence supporting these assertions. Beginning in 2009 the Colorado Family Planning Initiative abruptly expanded access to the full range of contraceptive methods through Colorado's Title X family planning clinics. Using eleven years of American Community Survey data linked to data from two decennial censuses, we assessed whether exposure to the program led to improvements in college completion among women. Exposure to the Colorado Family Planning Initiative at high school ages was associated with a population-level increase of 1.8-3.5 percentage points in women's on-time bachelor's degree attainment, which represents a 6-12 percent increase in women obtaining their degrees compared with earlier cohorts. Federal and state policies restricting or expanding access to the full range of contraceptive methods can affect women's attainment of higher education in addition to their reproductive health.

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.

US "Safety Net" Clinics Provide Access to Effective Contraception for Adolescents and Young Women, 2017-2019

Objectives. To describe patterns of providing moderately effective versus the most effective contraception and of providing implants versus intrauterine devices in US community health centers. Methods. We conducted a historical cohort study (2017-2019). Outcomes were woman-level receipt of most effective contraception (long-acting reversible contraception; implants and intrauterine devices) or moderately effective contraception. We used logistic regression to identify patient and clinic factors associated with providing (1) most versus moderately effective methods, and (2) implants versus intrauterine devices. We calculated adjusted probabilities for both outcomes by age group. Results. We included 199 652 events of providing contraception to 114 280 women in 410 community health centers. Adjusted probabilities were similar across age groups for moderately versus most effective methods. However, the adjusted marginal means for receiving an implant compared with an intrauterine device were highest for adolescents (15-17 years: 78.2% [95% confidence interval (CI) = 75.6%, 80.6%]; 18-19 years: 69.5% [95% CI = 66.7%, 72.3%]). Women's health specialists were more likely to provide most versus moderately effective contraception. Conclusions. Community health centers are an important access point for most effective contraception for women of all ages. Adolescents are more likely to use implants than intrauterine devices. (Am J Public Health. 2022;112(S5):S555-S562. https://doi.org/10.2105/AJPH.2022.306913).