Improving the Quality of Family Planning Services: The Role of New Federal Recommendations

Abstract

This article provides a brief overview of Federal guidelines developed by the Centers for Disease Control and Prevention and the United States Office of Population Affairs on how to deliver quality family planning services. This article describes how the recommendations were developed, summarizes key points, and outlines steps that will be taken to disseminate and increase the use of the recommendations by primary care providers.

Introduction

Over the course of a lifetime, most individuals will make decisions related to childbearing, that is, how to prevent or achieve pregnancy so that they can achieve their desired number and spacing of children. On any given day, 62 million women of reproductive age aged 15–44 years, (20% of the total population) and their partners are grappling with these issues.¹

Many Americans face challenges in preventing pregnancy. About one-half (49%) of the 6.7 million pregnancies each year (3.2 million) are unintended.² Approximately 700,000 of these pregnancies are to women less than 20 years of age;³ many teen mothers will achieve less education and lower incomes, while their children will experience higher rates of negative outcomes such as poorer health, lowered academic achievement, and higher rates of teen pregnancy for female children and incarceration for male children.⁴ Taxpayers also pay a high price for the nation’s high rate of teen and unintended pregnancy. For example, the cost of teen pregnancy has been estimated at $10.9 billion per year.⁵ Two-thirds of births resulting from unintended pregnancies among women of all ages—more than one million births—are publicly funded; the direct medical cost of those births is estimated at $11.1 billion.⁶ Recognizing its importance, the prevention of teen and unintended pregnancy has been included in the United States’ National Prevention Strategy⁷ and Healthy People 2020 Objectives.⁸

On the other hand, many Americans face challenges in achieving pregnancy. Almost seven million women ages 15–44 years had impaired fecundity (that is, had an impaired ability to get pregnant or carry a baby to term), and 1.5 million married women ages 15–44 years were infertile (that is, were unable to get pregnant after at least 12 consecutive months of unprotected sex with her husband).⁹ Many cases of infertility occur as a result of untreated sexually transmitted diseases (STD).¹⁰

Fortunately, we have a solution: family planning services. Family planning services are designed to help individuals achieve their childbearing goals, and traditionally include both contraceptive and STD services. Further, there are existing clinical recommendations that describe how to provide some aspects of family planning services. For example, Centers for Disease Control and Prevention (CDC)’s Medical Eligibility Criteria for Contraceptive Use describes what contraceptive methods can be safely used by women with different medical conditions and other characteristics. CDC’s STD Treatment Guidelines describe how to treat an individual woman or man who presents with signs and symptoms of a sexually transmitted disease.

However, no existing guidelines addressed the broader question of what is the full range of family planning services that should be offered to a client of reproductive age? In addition, there were important gaps in the existing guidelines, for example, no guidelines described how to provide contraceptive counseling, or how to meet the special reproductive health needs of adolescent clients. This article provides a brief overview of new Federal guidelines designed to address these gaps. Entitled Providing Quality Family Planning Services¹¹ (QFP), we will describe how the recommendations were developed, summarize key points, and outline steps that will be taken to disseminate and increase their use by providers of family planning services.

Description

Process of developing the recommendations

The recommendations were developed jointly under the auspices of CDC’s Division of Reproductive Health and the Health and Human Services Office of Population Affairs (OPA), in consultation with a wide range of experts and key stakeholders. The collaboration drew on the strengths of both agencies. CDC has a long-standing history of developing evidence-based recommendations for clinical care, and OPA’s Title X Family Planning Program has served as the national leader in direct family planning service delivery since the Title X program was established in 1970.

Every effort was made to develop the guidelines in accordance with the highest standards, which emphasize the use of evidence to the extent possible and transparency in the process of developing the recommendations. A multistage process was used to develop the recommendations that included the following: extensive input from an expert work group comprised of family planning clinical providers, program administrators, representatives from relevant federal agencies, and professional medical associations; systematic reviews of the literature focused on three priority topics (i.e., counseling and education, serving adolescents, and quality improvement); and consultation about the findings with technical panels comprising subject matter experts (one panel for each priority topic); a comprehensive synthesis of existing clinical recommendations on women’s and men’s preventive services was compiled from more than 35 federal and professional medical associations. CDC and OPA staff considered the individual feedback from expert work group and technical panel members when finalizing the core recommendations.

Key recommendations

The key recommendations address four main topics. They (1) define what services to offer clients in the context of a family planning visit, (2) describe how to provide contraceptive services, (3) address the special needs of adolescent clients, and (4) highlight the importance of quality improvement (see Table 1).

Table 1.

Summary of Key Recommendations from Providing Quality Family Planning Services

	Summary of key recommendations
Services to offer clients in the context of a family planning visit	Family planning services include contraceptive services for clients who want to prevent pregnancy and space births, pregnancy testing and counseling, assistance to achieve pregnancy, basic infertility services, STD services (including HIV testing), and other preconception health services, such as screening for obesity, smoking, and mental health. Family planning services should also provide related reproductive health services (for example, breast and cervical cancer screening). Family planning services should be offered to clients whose primary reason for a client’s visit to a health care provider is related to preventing or achieving pregnancy. They should also be offered to clients of reproductive age whose visit to a health care provider is not related to preventing or achieving pregnancy. QFP recommends how to provide each family planning service, drawing upon existing recommendations from Federal (i.e., CDC and the US Preventive Services Task Force) and professional medical associations (e.g., the American Academy of Pedatrics’ Bright Futures, American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, and the American Urological Association).
Contraceptive services	Key steps in providing contraceptive services are to: (1) establish and maintain rapport with the client; (2) obtain clinical and social information from the client; (3) work with the client interactively to select the most effective and appropriate contraceptive method for him or her; (4) conduct a physical assessment related to contraceptive use, when warranted; and (5) provide the contraceptive method along with instructions about consistent and correct use, help the client develop a plan for using the selected method and for follow up, and document understanding. A broad range of methods, including long-acting reversible contraception (LARCs) (i.e., intrauterine devices, implants), should be discussed with all women and adolescents, if medically appropriate. Providers are encouraged to present information on potential reversible methods of contraception by using a tiered approach (i.e., presenting information on the most effective methods first, before presenting information on less effective methods). This information should include an explanation that LARC methods are safe and effective for women who have never given birth, including adolescents. The content, format, method, and medium for delivering education should be evidence based, and the client’s understanding of the most important information about her or his chosen contraceptive method should be documented in the medical record.
Adolescent clients	Services for adolescents should be provided in a “youth-friendly” manner, in accordance with the World Health Organization recommendation that they be accessible, equitable, acceptable, appropriate, comprehensive, effective, and efficient for youth. Providers should give comprehensive information to adolescent clients about how to prevent pregnancy. This information should clarify that avoiding sex (i.e., abstinence) is the most effective way to prevent pregnancy and STDs. If the adolescent indicates that she or he is not or might not be abstinent, providers should give information about contraception and help her or him to choose a method that best meets her or his individual needs, including the use of condoms to reduce the risk of STDs. Providers of family planning services should offer confidential services to adolescents and observe all relevant state laws and any legal obligations, such as notification or reporting of child abuse, child molestation, sexual abuse, rape, or incest, as well as human trafficking Providers should encourage and promote communication between the adolescent and his or her parent(s) or guardian(s) about sexual and reproductive health. In addition to providing postpartum contraception, providers should refer pregnant and parenting adolescents to home visiting and other programs that have been shown to provide needed support and reduce rates of repeat teen pregnancy.
Quality improvement	Service sites that offer family planning services should have a system for conducting quality improvement, which is designed to review and strengthen the quality of services on an ongoing basis. Service sites that offer family planning services should select, measure, and assess at least one intermediate or outcome measure on an ongoing basis, for which the service site can be accountable.

CDC, Centers for Disease Control and Prevention; HIV, human immunodeficiency virus; QFP, quality family planning; STD, sexually transmitted disease.

Definition of family planning services.

Family planning services include contraceptive services for clients who want to prevent pregnancy and space births, pregnancy testing and counseling, assistance to achieve pregnancy, basic infertility services, STD services (including HIV testing), and other preconception health services (see Fig. 1). STD/HIV and other preconception health services are considered family planning services because they improve women’s and men’s health and can influence an individual’s ability to conceive or to have a healthy birth outcome.^12–14

FIG. 1.

Family planning, related preventive services, and other preventive health services.

Family planning services are embedded within a broader framework of preventive health services. Related preventive health services include services that are considered to be beneficial to reproductive health, are closely linked to family planning services, and are appropriate to deliver in the context of a family planning visit but do not directly contribute to achieving or preventing pregnancy. Breast and cervical cancer screening are examples. Other preventive health services include the full range of preventive services for women and men, such as essential preventive health services for women that were recommended by the Institute of Medicine but are not included in QFP. Screening for lipid disorders or colorectal cancer are examples of this type of service.

Contraceptive services.

As noted above, other guidelines address aspects of contraceptive service delivery, but QFP builds on these guidelines and addresses gaps to recommend a comprehensive, five-step approach to providing contraceptive services. An important addition is the integration of an evidence-informed process of counseling and education that emphasizes using a client-centered approach. The recommendations also highlight the safety and effectiveness of long-acting reversible contraception, and encourage presenting information about contraceptive methods in a tiered approach (i.e., in which the most effective methods are described first).

Adolescent clients.

Given the importance of teen pregnancy, the special needs of adolescent clients are highlighted. Recommendations address the need to provide adolescents with comprehensive information about birth control options, meeting their needs for confidential and youth-friendly services, encouraging parent–child communication about sexual health matters, and not missing opportunities to work with pregnant and parenting teens to avoid repeat teen pregnancy.

Quality improvement.

A key premise of the recommendations is that improving the quality of care will lead to improved health outcomes.¹⁵ Steps that service sites can take to improve the quality of services is highlighted as an important way to continuously strengthen services and thereby help clients achieve their family planning goals.

Implementation

Studies of guideline adoption and use have often shown relatively low rates of use, ranging from 27%–67%,^16–19 and that after specific guideline promotion activities has ceased, adherence rates often returned to baseline levels.²⁰ CDC and OPA intend to take steps to increase widespread adoption and sustained use of the family planning guidelines by a broad range of providers.

The implementation plan recognizes that successful approaches are multi-faceted and increase knowledge and awareness, but also build skills; make the guidelines easier to use (e.g., via job aids); obtain peer and opinion leader support; address institutional changes that make the guidelines easier to implement; and create incentives for performing the desired behaviors.^21–29 Further, efforts to support adoption of clinical guidelines by providers should be an iterative and phased process that actively engages a variety of stakeholders over time. Accordingly, the implementation plan is comprised of four phases:

Phase one: The initial release.

A primary goal of the initial release of the program guidelines is to increase awareness within the Title X provider network that the Title X program guidelines have been released and of plans to help providers implement them. A secondary goal is to increase awareness of QFP within the non-Title X primary care community.

Phase two: Development of implementary tools.

The primary goal of this phase is to develop and provide training/tools that will facilitate implementation of the program guidelines in Title X service sites as well as by other providers in a range of primary care settings (for by information, see www.fpntc.org).

Phase three: Other efforts to increase awareness and use of the guidelines.

This phase will extend over several years, with the primary goal to continue efforts to increase use of QFP, but with a greater emphasis on persuading key gatekeepers and opinion leaders in the broader (i.e., non-Title X) community of primary care and family planning service providers.

Phase four: Periodic updates to the guidelines.

There will be an ongoing need to disseminate information to providers and other key stakeholders as the program guidelines are updated. It has been estimated that 90% of clinical practice guidelines are still valid in 3.6 years, but that 50% are out of date in 5.8 years.^30,31 CDC and OPA intend to continuously monitor and update QFP in accordance with recommended procedures.³² This will include the following: (1) conducting an ongoing review of revisions to CDC and U.S. Preventive Services Task Force (USPSTF) recommendations, and incorporating them into QFP on a regular basis; (2) monitoring major breakthroughs in science or policy (e.g., a defining new study is released or there is a change in a major professional medical recommendation), and modifying QFP after consultation with an ad hoc group of experts; and (3) conducting a comprehensive review of the entire guidelines document every 3–5 years, to include systematic reviews of all new evidence in existing topical areas, as well as reviews of new content areas to be incorporated into the guidelines, if needed.

Evaluation

A key assumption of the dissemination plan is that implementation of QFP will change how providers deliver services, which in turn will change the behavior of clients, thereby leading to improvement in health outcomes.³³ The evaluation plan is still under development, but activities include conducting a nationally representative survey of public and private family planning providers and service sites to monitor use of QFP over a 2- to 3-year period after the recommendations are released. We will also conduct national surveillance activities using the National Survey of Family Growth and the Pregnancy Risk Assessment Monitoring System to monitor coverage of the services recommended in QFP and sources of care, to identify subpopulations that are less likely to receive the recommended services, and to monitor these trends over time. Finally, we will monitor other types of change that demonstrates increased use of QFP (e.g., designation of appropriations or funding, development of action group/task forces, advocacy initiatives, educational efforts, or research initiatives that are based on QFP).

Conclusions

The United States continues to face substantial challenges to improving the reproductive health of the US population. The recommendations in this report can contribute to improved reproductive health by defining a core set of family planning services for women and men, describing how to provide contraceptive and other family planning services, recommending how to meet the special needs of adolescent clients, and encouraging use of quality improvement. Ultimately, we hope that this guidance will be used by primary care providers to offer the family planning services that will help individuals and couples achieve their desired number and spacing of children and will increase the likelihood that those children are born healthy.