The Colorado Initiative to Reduce Unintended Pregnancy: Contraceptive Access and Impact on Reproductive Health

Abstract

The Colorado Initiative to Reduce Unintended Pregnancy, including its largest subproject, the Colorado Family Planning Initiative, had a significant impact on contraceptive access during and after the project period. This coordinated and multilevel initiative improved reproductive health outcomes by driving change in public health systems, advancing statewide policies, building capacity through training and technical assistance, and increasing public awareness and education. Lessons learned from the implementation and outcomes of the Colorado Initiative to Reduce Unintended Pregnancy continue to inform contraceptive access efforts. (Am J Public Health. 2022;112(S5):S532–S536. https://doi.org/10.2105/AJPH.2022.306891)

The Colorado Initiative to Reduce Unintended Pregnancy (hereafter “Colorado Initiative”) was a multiyear project involving multilevel interventions and implemented by a broad range of partners across Colorado with the goal of increasing access to contraception. The Colorado Initiative was conducted between 2008 and 2016 and focused on four strategies: (1) increasing access to quality family-planning services, (2) increasing the availability of IUDs (intrauterine devices) and implants, (3) promoting healthy decisions and planning, and (4) improving public policy and practices.¹ We describe the implementation and long-term impact of the Colorado Family Planning Initiative (CFPI) project, the largest project of the Colorado Initiative, and highlight lessons learned that may inform the implementation and evaluation of future contraception access projects.

INTERVENTION AND IMPLEMENTATION

In Colorado, a large network of stakeholders was identified to inform Colorado Initiative activities during the project period. The Colorado Initiative distributed funding to 17 grantee organizations, reaching 110 public health centers, advocacy coalitions, and reproductive justice and community-based organizations (Figure A, available as a supplement to the online version of this article at http://www.ajph.org).

The largest grantee funded by the Colorado Initiative was the Colorado Department of Public Health and Environment’s Title X Family Planning Program. This program formed the CFPI and used an existing network of 69 family-planning clinics located in public health departments, community health centers, hospitals, and urban and rural school-based health centers to implement clinic-based strategies to address the four priority areas for the Colorado Initiative. Before the CFPI, access to long-acting reversible contraceptive (LARC) methods was limited because of constraints such as device cost² or lack of provider proficiency with device insertion.³ The CFPI aimed to reduce such barriers and increase access through the Title X network by increasing capacity, providing LARCs at no cost, improving community outreach and health education through a public awareness campaign, and supporting state policy changes to family planning.

PLACE, TIME, AND PERSONS

Colorado was selected as a site for this initiative because it (1) is a midsized state with a diverse population, (2) had an established family-planning network, and (3) had a high unintended pregnancy rate before the start of the project period.¹ In Colorado, the Colorado Initiative supported the CFPI from 2009 to 2014. The CFPI network of Title X family-planning clinics covered all 37 counties with Title X family-planning clinics in the state. These counties, 13 designated as urban, 14 as rural, and 10 as frontier, include 95% of Colorado’s population.⁴ Finally, we assembled CFPI data through 2019 to identify long-term trends in the outcomes of interest, including changes in family-planning service utilization, contraceptive provision, adolescent birth, and abortion rates.

In 2008, the Colorado Title X Program reached 52 645 clients (46 348 women and 6297 men), with more than half of clients younger than 25 years. The racial and ethnic diversity of the clientele was mostly representative of Colorado’s overall population (77% White, 4% Black, 3% other), with the exception of 40% of clients who identified as Hispanic, which was nearly double the number of Hispanic residents in Colorado (21%). Finally, more than 70% of clients reported an income below 100% of the federal poverty level (as determined by the US Department of Health and Human Services for that year).

PURPOSE

To implement Colorado Initiative strategies, all 69 Title X clinics received CFPI funds. Participation required clinics to provide LARCs at no cost. Most clinics purchased and stocked LARC devices onsite. Smaller clinics contracted with local providers to provide devices and sterilizations. Clinics also engaged in activities related to hiring and training staff, extending clinic hours, purchasing equipment or electronic health records, and expanding community outreach and education to reduce barriers and increase access to quality family-planning services.

CFPI activities also included training and technical assistance on contraceptive counseling, clinic workflows, and billing and coding practices through annual conferences and quarterly meetings. In 2015, these annual trainings were expanded to include LARC device insertions, training 550 clinicians statewide over a four-year period.¹ After the CFPI received criticism for prioritizing LARCs and using tiered counseling methods, trainings were modified in 2016 to ensure that program activities were patient centered, focused on reproductive autonomy, and provided equitable access to all methods.

Two coalitions emerged that engaged Title X clinics participating in the CFPI in advocacy efforts to influence statewide policies and practices, including improvements to Medicaid reimbursement, confidentiality protections, and state funding for family planning.

Additional community education and outreach activities were launched through a public awareness campaign focused on normalizing sexual and reproductive health topics among individuals, families, and communities.

EVALUATION AND ADVERSE EFFECTS

We compared reproductive health indicators at three points—the year before the initiative (2008), at the end of the CFPI (2014), and five years after the project ended (2019). During the CFPI, the total number of women seen in Title X clinics increased by 2.5%. Table 1 also shows that the improvements in reproductive health indicators were sustained through the five years after the intervention. From 2008 to 2019 the proportion of female contraceptive clients using a LARC increased from 6% to 32%, whereas the proportion using combined hormonal methods (i.e., pills, patches, and rings) decreased from 48% to 25%. Female clients using Depo Provera and other methods remained unchanged from 2008 to 2019. Although the intervention reached people across the state, the outcomes we report here focus on adolescents and young adults. Statewide, large declines were seen in the adolescent birthrate (from 11.2 per 1000 in 2008 to 3.9 per 1000 in 2019), the adolescent abortion rate (from 39.6 per 1000 in 2008 to 13.5 per 1000 in 2019), and the number of second-order or higher births to adolescents (from 1258 in 2008 to 290 in 2019). We did not identify any adverse effects during the CFPI or during the five-year follow-up period.

TABLE 1—

Selected Characteristics and Reproductive Health Indicators of Title X Female Clients: Colorado, 2008, 2014, 2019

Characteristica or Reproductive Health Indicatorb	2008, No. (%)	2014, No. (%)	2019, No. (%)
Total	46 348	47 513	43 774
Age, y
< 15–19	12 256 (26.4)	11 392 (24.0)	9 801 (22.4)
20–24	13 381 (28.9)	13 237 (27.9)	10 599 (24.2)
25–34	14 423 (31.1)	15 238 (32.1)	14 228 (32.5)
≥ 35	6 288 (13.6)	7 646 (16.1)	9 146 (20.9)
Race
White	35 565 (76.7)	32 696 (68.8)	30 855 (70.5)
Black	2 043 (4.4)	3 387 (7.1)	4 263 (9.7)
Other/more than 1 race	1 479 (3.2)	1 730 (3.6)	2 380 (5.4)
Unknown/not reported	7 261 (15.7)	9 700 (20.4)	6 276 (14.3)
Ethnicity
Hispanic or Latino	18 589 (40.1)	22 321 (47.0)	23 017 (52.6)
Not Hispanic or Latino	25 638 (55.3)	22 216 (46.8)	19 123 (43.7)
Unknown/not reported	2 121 (4.6)	2 976 (6.3)	1 634 (3.7)
% of FPLc
≤ 100	38 577 (73.3)	41 743 (74.9)	38 387 (71.6)
101–150	7 657 (14.5)	6 853 (12.3)	6 611 (12.3)
151–200	2 959 (5.6)	3 207 (5.8)	3 729 (7.0)
201–250	1 381 (2.6)	1 584 (2.8)	1 722 (3.2)
> 250	1 684 (3.2)	2 316 (4.2)	3 165 (5.9)
Unknown/not reported	387 (0.7)	0 (0.0)	0 (0.0)
Insurance typec
Public	4 578 (8.7)	16 002 (28.7)	18 926 (35.3)
Private	4 483 (8.5)	6 825 (12.3)	8 347 (15.6)
Uninsured	38 257 (72.7)	29 271 (52.5)	25 666 (47.9)
Unknown/not reported	5 327 (10.1)	3 605 (6.5)	675 (1.3)
Overall method mix	46 348	47 513	43 774
IUDs	2 653 (5.7)	6 237 (13.1)	7 347 (16.8)
Implants	263 (0.6)	5 262 (11.1)	6 755 (15.4)
Injections	6 082 (13.1)	6 945 (14.6)	5 908 (13.5)
Pills	18 765 (40.5)	12 412 (26.1)	9 247 (21.1)
Vaginal ring	1 812 (3.9)	1 938 (4.1)	1 170 (2.7)
Patch	1 759 (3.8)	670 (1.4)	303 (0.7)
Female clients using all other contraceptive methodsd	6 511 (14.0)	6 619 (13.9)	6 641 (15.2)
Female clients who were pregnant, seeking pregnancy, not using a method for another reason, or whose method was unknown/not reported	8 503 (18.3)	7 430 (15.6)	6 403 (14.6)
Female clients using IUDs, by age, y	2 653	6 237	7 347
< 15–19	190 (7.2)	771 (12.4)	958 (13.0)
20–24	642 (24.2)	1 810 (29.0)	1 766 (24.0)
25–34	1 261 (47.5)	2 425 (38.9)	2 735 (37.2)
≥ 35	560 (21.1)	1 231 (19.7)	1 888 (25.7)
Female clients using hormonal implants, by age, y	263	5 262	6 755
< 15–19	111 (42.2)	1 973 (37.5)	2 264 (33.5)
20–24	65 (24.7)	1 793 (34.1)	1 913 (28.3)
25–34	66 (25.1)	1 162 (22.1)	1 736 (25.7)
≥ 35	21 (8.0)	334 (6.3)	842 (12.5)
Female clients using pills, by age, ye	18 765	12 412	9 247
< 15–19	5 233 (27.9)	2 813 (22.7)	2 002 (21.7)
20–24	not reported	3 589 (28.9)	2 445 (26.4)
25–34	not reported	4 084 (32.9)	3 035 (32.8)
≥ 35	not reported	1 926 (15.5)	1 765 (19.1)
Female clients using 3-mo hormonal injectables, by age, y	5 482	6 945	5 908
< 15–19	1 194 (21.8)	2 061 (29.7)	1 688 (28.6)
20–24	1 754 (32.0)	1 821 (26.2)	1 392 (23.6)
25–34	1 775 (32.4)	1 972 (28.4)	1 659 (28.1)
≥ 35	759 (13.8)	1 091 (15.7)	1 169 (19.8)
Reproductive health indicator
Adolescent abortion rate: induced terminations of pregnancy among females 15–19 y per 1000 females 15–19 y	11.2	5.5	3.9
Adolescent birthrate: births to females 15–19 y per 1000 female population in the age group	39.6	19.8	13.5
No. second or higher order births to adolescents 15–19 y	1 258	511	290
Rapid repeat births: % of all repeat births among women of all ages that occur < 24 mo after the previous delivery	24.0	20.7	21.6
Average age at first birth, y	25.7	27.1	27.9

Note. FPL = federal poverty level; IUD = intrauterine device. We used FPL as determined by the US Health and Human Services in the specific year.

^aUS Department of Health and Human Services, Office of Population Affairs, “Family Planning Annual Report 2021” (https://opa.hhs.gov/research-evaluation/title-x-services-research/family-planning-annual-report/family-planning-0).

^bColorado Department of Public Health and Environment (https://drive.google.com/file/d/1eoY53hAMOaUiQ5_-iQU0H84I-vkPJRq9/view).

^cMale plus female Title X family-planning users.

^dFemale sterilization, cervical cap, diaphragm, sponge, female condom, spermicide (used alone), fertility awareness method, lactational amenorrhea method, abstinence, withdrawal, other, vasectomy, male condom.

^eIn 2008 there were 18 765 reported oral contraceptive users, including 5305 aged < 15–19 y. In the 2008 “Family Planning Annual Report” for those aged 20–39 y, there are 10 616 cases of missing data on age.

SUSTAINABILITY

The Colorado Initiative created momentum to build statewide contraceptive access initiatives across the country and provided lessons and recommendations for future programs:

• 1.Integrate principles of person centeredness and equity into program planning, implementation, and evaluation at the outset.
• 2.Partner with a diverse group of stakeholders, including advocates and reproductive justice organizations. Engage communities in identifying their strengths and opportunities, then codesign programs and solutions together, building strategic priorities, goals, and metrics that are nonstigmatizing, culturally relevant, and person centered.
• 3.Share the success of the project through publications^1,3,4,6 and advocacy efforts. In Colorado, this increased the visibility of the program and led to an increase in state funding for family planning. However, the project was criticized for highlighting costs that governmental programs avoided through reductions in adolescent birthrates as a reason for expanding funding for the program.
• 4.Recognize the importance of language and messaging. Provide context when describing outcomes and successes to avoid stigma and marginalization.
• 5.Create an ongoing culture of continuous improvement. Provide flexibility to shift priorities as the field of reproductive health evolves and allow local approaches to implementation.

PUBLIC HEALTH SIGNIFICANCE

By increasing access to contraception broadly, the CFPI profoundly affected women’s reproductive health in Colorado, and the impact was sustained after the initiative ended. Access to contraception matters to the lives of individuals and families and makes a measurable public health impact. The Colorado Initiative expanded contraceptive access and opportunity in Colorado and inspired other states⁷ to implement similar models.