Abstract
Objectives:
This study aims to describe aspects of the scope and quality of family planning services provided by US publicly funded health centers before the release of relevant federal recommendations.
Study design:
Using nationally representative survey data (N=1615), we describe four aspects of service delivery: family planning services provided, contraceptive methods provided onsite, written contraceptive counseling protocols and youth-friendly services. We created a count index for each issue and used multivariable ordered logistic regression to identify health center characteristics associated with scoring higher on each.
Results:
Half of the sample received Title X funding and about a third each were a community health center or health department clinic. The vast majority reported frequently providing contraceptive services (89%) and STD services (87%) for women in the past 3 months. Service provision to males was substantially lower except for STD screening. A total of 63% and 48% of health centers provided hormonal IUDs and implants onsite in the past 3 months, respectively. Forty percent of health centers included all five recommended contraceptive counseling practices in written protocols. Of youth-friendly services, active promotion of confidential services was among the most commonly reported (83%); offering weekend/evening hours was among the least (42%). In multivariable analyses, receiving Title X funding, having larger volumes of family planning clients and being a Planned Parenthood clinic were associated with higher scores on most indices.
Conclusion:
Many services were consistent with the recommendations for providing quality family planning services, but there was room for improvement across domains and health centers types.
Implications statement:
As assessed in this paper, the scope and quality of these family planning services was relatively high, particularly among Planned Parenthood clinics and Title X-funded centers. However, results point to important areas for improvement. Future studies should assess change as implementation of recent family planning service recommendations continues.
Keywords: Contraceptive methods, Contraceptive counseling, Youth-friendly services, Title X
1. Introduction
In April 2014, the Centers for Disease Control and Prevention (CDC) and HHS’s Office of Population Affairs (OPA) released Providing Quality Family Planning Services (QFP) [1]. QFP includes numerous recommendations related to the content of clinical care, screening, counseling and supportive services that should be provided whenever family planning services are offered. We focus on four areas of service delivery covered in QFP. First, QFP recommends that family planning services always include (1) contraception for clients who want to prevent pregnancy, (2) pregnancy testing and counseling, (3) help for clients wishing to achieve pregnancy (including basic infertility services), (4) preconception health care services1 and (5) STD (including HIV) services [1]. Each of these services is needed to help individuals and couples achieve their desired number and spacing of healthy children [2,3]. Second, QFP recommends that a broad range of FDA-approved contraceptive methods be made available onsite, and secondarily by referral if needed, to ensure that clients can select and use methods that meet their needs [1] (p.8, 11).
Third, QFP provides recommendations about how to provide contraceptive counseling in a client-centered manner, which includes assessing the client’s pregnancy intentions/reproductive life plan, using open-ended questions to build rapport, educating clients about the effectiveness of different contraceptive methods and that long-acting reversible contraception (LARC) is safe for adolescents and helping clients think about and plan to address potential barriers to using their selected method [1,4,5]. Fourth, QFP recommends providing “youth-friendly services” generally ([1], p.7, 13) and highlights the promotion of confidentiality, parent–child communication and adolescent-focused educational materials [6,7].
Prior to the release of the QFP, we sought to describe family planning service provision in the US and conducted a survey of administrators from a national sample of publicly funded health centers that provided family planning services. The objective of this paper is to offer a baseline view of four aspects of family planning services among those centers and inform efforts to assure high-quality family planning services going forward.
2. Materials and methods
From June 2013 to May 2014, we sent surveys to a random sample of 4000 publicly funded health centers identified from a Guttmacher Institute (New York, NY) database. By design, half were recipients of federal funds from the Title X family planning program administered by the HHS OPA, while the other half received other types of public funding. The sample included community health centers, Planned Parenthood centers, hospital-based clinics, health departments and other health centers that offered family planning. We mailed surveys to health centers and asked administrators to complete it online or return it using a postage-paid envelope. We sent reminder postcards and follow-up mailings and made phone calls to nonrespondents. Response rates were calculated based on recommendations from the Council of American Survey Research Organizations (CASRO). The project was determined to be “nonresearch, public health practice,” so CDC’s institutional review board approval was not needed.
2.1. Outcome measures
Aspect 1:Scope of family planning services provided.
We asked questions about the frequency of providing each of the following family planning services in the last 3 months (never/rarely/occasionally/frequently): pregnancy diagnosis and counseling, contraceptive services, basic infertility services, STD screening and preconception health care. These were asked separately for male and female clients, except for pregnancy diagnosis. We focused on “frequent” provision for most services though focused on “frequent” or “occasional” provision for basic infertility services.
Aspect 2:Contraceptive methods provided onsite.
To describe the range of contraceptive methods provided onsite, we used questions about whether or not 11 reversible contraceptive methods were provided onsite in the last 3 months (Table 2).
Table 2.
Service characteristics of US publicly funded health centers that offered family planning services, 2013–2014a
| Title X funding status | Type of health center | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Overall | Yes | No | Planned Parenthood | Community health centers | Health departments | Hospitals | Other | |||
| Scope of family planning services provided (frequently, last 3 months)b | ||||||||||
| Pregnancy diagnosis and counseling | 75% | 82% | 68% | * | 94% | 65% | 80% | 83% | 72% | * |
| Contraceptive services for women | 88% | 95% | 82% | * | 100% | 78% | 96% | 89% | 90% | * |
| Contraceptive services for men | 31% | 34% | 27% | * | 46% | 25% | 29% | 21% | 42% | * |
| Basic infertility services for women | 36% | 35% | 37% | 28% | 40% | 29% | 53% | 35% | * | |
| Basic infertility services for men | 15% | 14% | 16% | 12% | 18% | 10% | 17% | 17% | * | |
| STD screening for women | 87% | 92% | 82% | * | 99% | 79% | 91% | 90% | 88% | * |
| STD screening for men | 70% | 77% | 63% | * | 92% | 61% | 77% | 42% | 72% | * |
| Preconception health care for women | 53% | 58% | 47% | * | 38% | 48% | 62% | 56% | 51% | * |
| Preconception health care for men | 17% | 16% | 18% | 16% | 18% | 13% | 14% | 22% | * | |
| Contraceptive methods provided onsite (last 3 months) | ||||||||||
| Levonorgestrel IUD | 63% | 67% | 60% | * | 95% | 59% | 60% | 75% | 58% | * |
| Copper IUD | 59% | 65% | 53% | * | 98% | 53% | 54% | 75% | 50% | * |
| Implant | 48% | 50% | 45% | * | 91% | 41% | 38% | 69% | 46% | * |
| DMPA (3-month injectable) | 96% | 98% | 93% | * | 100% | 93% | 98% | 96% | 93% | * |
| Patch | 60% | 66% | 55% | * | 91% | 58% | 58% | 59% | 55% | * |
| Vaginal ring | 68% | 79% | 58% | * | 95% | 58% | 75% | 68% | 64% | * |
| Combined oral contraceptives | 88% | 96% | 79% | * | 98% | 81% | 96% | 76% | 86% | * |
| Progestin-only oral contraceptives | 78% | 87% | 68% | * | 98% | 68% | 86% | 69% | 72% | * |
| Emergency contraception | 71% | 87% | 55% | * | 99% | 51% | 84% | 63% | 75% | * |
| Male condom | 88% | 97% | 78% | * | 100% | 76% | 98% | 73% | 90% | * |
| Female condom | 44% | 53% | 35% | * | 75% | 34% | 47% | 35% | 43% | * |
| Content included in contraceptive counseling written protocolsc | ||||||||||
| Using open-ended questions | 49% | 65% | 31% | * | 80% | 25% | 65% | 38% | 48% | * |
| Assessing client’s reproductive life plan | 57% | 76% | 35% | * | 92% | 30% | 76% | 42% | 54% | * |
| Presenting information regarding potential contraceptive methods with the most effective methods presented first (tiered approach) | 59% | 75% | 40% | * | 82% | 36% | 77% | 46% | 58% | * |
| Helping client think about potential barriers to using their selected method correctly and develop a plan to deal with those barriers | 56% | 74% | 35% | * | 79% | 33% | 75% | 42% | 53% | * |
| Informing clients that LARCs are safe and effective for adolescents | 59% | 77% | 39% | * | 80% | 35% | 79% | 48% | 57% | * |
| Youth-friendly services (frequently, last 3 months | ||||||||||
| Offered educational materials for adolescents | 53% | 64% | 42% | * | 58% | 41% | 63% | 56% | 58% | * |
| Offered same-day appointments for clinical services | 76% | 69% | 84% | * | 89% | 91% | 56% | 61% | 82% | * |
| Offered weekend or evening hours for clinical services | 42% | 34% | 50% | * | 68% | 59% | 19% | 27% | 40% | * |
| Offered adolescent only hours or days for clinical services | 16% | 19% | 12% | * | 9% | 15% | 16% | 25% | 16% | * |
| Offered website that allows clients to make appointments onlined | 21% | 15% | 27% | * | 61% | 29% | 5% | 18% | 13% | * |
| Offered time alone with provider for adolescents that came with parent/guardian | 78% | 86% | 70% | * | 91% | 65% | 88% | 90% | 75% | * |
| Actively encouraged communication between adolescent and parents on sex and RH issues | 83% | 90% | 76% | * | 97% | 74% | 91% | 83% | 80% | * |
| Actively promoted the availability of confidential services to adolescents | 83% | 91% | 74% | * | 95% | 72% | 92% | 89% | 80% | * |
| Conducted community education in schools or other youth-serving organizations (last 12 months)d | 73% | 76% | 70% | * | 75% | 71% | 78% | 51% | 75% | * |
| Conducted community education through websites or social media (last 12 months)d | 64% | 66% | 63% | 91% | 64% | 60% | 46% | 67% | * | |
Weighted percentages
Basic infertility services were included if provided “frequently” or “occasionally.”
Chi-square tests of these row differences were statistically significant at p<.05.
Many respondents skipped these questions, so N values are reduced for this series compared to the others.
These items’ responses were coded as yes (vs. no).
Aspect 3:Contraceptive counseling components included in written protocols.
We used five questions that asked whether certain QFP-recommended counseling practices were included in written counseling protocols (yes/no) (Table 2).
Aspect 4:Youth-friendly services.
We used 10 questions about the provision of services we considered youth-friendly (Table 2). We assessed seven in terms of frequency of provision in the prior 3 months (never/rarely/occasionally/frequently), focusing on “frequent” provision. Two additional questions assessed community education through the internet/social media or through schools/other youth-serving organizations in the prior 12 months (yes/no). We also used a question about having a website that allows clients to make appointments online (yes/no).
For each aspect, we developed a simple, unweighted count index that summed the number of individual items that the health center reported providing. Respondents missing an answer to any item in an index were excluded from calculation of that index.
2.2. Independent variables
We used other health center characteristics to examine variation in outcomes: type of health center (community health center, Planned Parenthood, health department, hospital or other), Title X funding status (yes/no), type of area served (urban/suburban, rural or mixed), geographic location (with states coded into four regions across the US), approximate number of clients seen in the last year (six categorical response options ranging from <500 to 50,000+) and approximate number of family planning clients seen in the last year (five categorical response options ranging from <500 to 10,000+).
2.3. Analytic approach
We calculated the prevalence of each item in the four count indices and examined variation by Title X funding status and health center type. We also conducted ordered logistic regression to identify characteristics associated with scoring higher or lower on each index. Each multivariable model failed tests of proportionate odds that underlie the statistical assumptions for standard ordered logistic regression, so we conducted generalized ordered logistic regression models. However, given that the interpretation of the results was similar and the exploratory nature of this analysis, we opted to present the standard results for greater simplicity and clarity. Analyses were conducted in StataV.12 and weighted for the complex sampling design and nonresponse, to represent publicly funded health centers that offered family planning nationwide.
3. Results
3.1. Sample characteristics
The final CASRO response rate was 49%, yielding 1615 surveys. Clinic administrators completed 41% of surveys; nurse/nurse practitioner managers, 39%; medical directors, 11%; or other staff, 18% (data not shown). Thirty-seven percent of surveys were from community health centers and 31% were from health departments (Table 1). The sample included health centers from across regions of the US, and about half (48%) reported serving primarily rural areas. Approximate patient case load in the last year varied widely.
Table 1.
Characteristics of US publicly funded health centers that offered family planning services, 2013–2014a
| Type of health center (N=1615) | Total clients seen, last year (N=1564) | ||
| Planned Parenthood (n= 168) | 9% | <500 | 7% |
| Community health center (n=427) | 37% | 500–999 | 8% |
| Health department (n=684) | 31% | 1000–4999 | 35% |
| Hospital (n=84) | 7% | 5000–9999 | 19% |
| Other type (n=252) | 16% | 10,000–49,999 | 27% |
| 50,000+ | 4% | ||
| Title X funding status (N=1615) | |||
| Yes (n=1045) | 49% | Total family planning clients seen, last year (N=1530) | |
| No (n=570) | 51% | <500 | 30% |
| 500–999 | 20% | ||
| Geographic location (N=1563) | 1000–4999 | 36% | |
| Northeast/Mid-Atlantic | 18% | 5000–9999 | 8% |
| South/Southwest | 33% | 10,000+ | 5% |
| Midwest | 19% | ||
| West | 30% | Mean percentage of family planning clientsb: | |
| Who were less than age 20 years | 26% | ||
| Type of area served (N=1598) | Who were male | 14% | |
| Mostly urban/suburban | 31% | ||
| Mostly rural | 48% | ||
| Both rural and urban/suburban | 21% |
Unweighted N values; weighted proportions.
Many respondents were missing data for these questions. N=1375 for adolescent clients and N=1091 for male clients.
3.2. Scope of family planning services provided
In the 3 months prior to the survey, nearly 90% of health centers frequently provided contraceptive services for women (88%) and STD screening for women (87%) (Table 2). Service provision to males for all family planning services except STD screening was lower. Title X funding status was associated with increased provision of 6 of 9 services. All types of health centers reported relatively high levels of providing contraceptive services and STD services for women. Health centers also reported similarly low levels of having provided basic infertility services and preconception health services to men. Large, statistically significant differences by health center characteristics were evident for other items. For example, frequent STD screening among men varied from 42% among hospitals to 92% among Planned Parenthoods.
3.3. Contraceptive methods provided onsite
Nearly all health centers (96%) reported providing injectable contraception (DMPA) onsite to clients in the last 3 months, and 88% reported providing combined oral contraceptives and male condoms onsite. Onsite provision of LARC was lower, with 63%, 59% and 48% for levonorgestrel IUD, copper IUD and implant, respectively. Female condoms were provided onsite the least frequently (44%). For every contraceptive method, Title X-funded centers had significantly increased prevalence of having provided the method onsite than those not receiving Title X funding. Nearly all Planned Parenthood centers had provided each method onsite (range 91–100%) apart from female condoms (75%), while other types of health centers ranged more widely across the methods.
3.4. Contraceptive counseling written protocols
Nearly 20% of respondents skipped questions about whether their health center’s written protocols included specific QFP recommendations. Of those with valid responses, between 49% and 59% of all health centers had individual practices in their written counseling protocols. A higher proportion of Title X health centers than non-Title X health centers reported having individual practices in a written protocol. At least 80% of Planned Parenthood centers reported having each of the items, with community health centers having the lowest prevalence of having each practice in a written protocol (range 25–36% across items).
3.5. Youth-friendly services
The most commonly reported youth-friendly services provided were active encouragement of parent–child communication on sex and reproductive health issues and active promotion of confidential services for adolescents (83% of health centers, overall, for both). In six of ten items, Title X-funded health centers exceeded those not funded by Title X, but they had lower prevalence for three, for example, offering same-day appointments (69% vs. 84%, respectively). Nearly all community health centers and Planned Parenthood clinics reported frequently providing same-day appointments in the last 3 months (91% and 89%, respectively), compared to 61% of hospitals and 56% of health departments. Only 5% of health departments offered web-based appointment setting, compared to 61% of Planned Parenthoods.
3.6. Service count indices
Table 3 describes the service count indices that we developed based on the individual items included in Table 2. The range for each one ran the full span of each count index and was fairly normally distributed, except for the one about written counseling protocols. The weighted means for three of four count indices (except scope of services provided) were highest for Planned Parenthood centers compared to other types of health centers. The index means were higher for health centers receiving Title X funding compared to those without Title X funding (statistical tests not shown).
Table 3.
Description of four indices of family planning services, among US publicly funded health centers providing family planning services, 2013–2014a
| Index of the scope of family planning services provided | Index of contraceptive methods provided onsite | Index of contraceptive counseling written protocolb | Index of youth-friendly services | |
|---|---|---|---|---|
| Description of index | ||||
| Number of health centers included | 1500 | 1413 | 1290 | 1442 |
| Index range | 0–9 | 0–11 | 0–5 | 0–10 |
| Percent with 0 index items | 6% | 3% | 29% | <1% |
| Percent with all index items | 5% | 17% | 40% | 1% |
| Index mean | 4.7 | 7.6 | 2.8 | 5.9 |
| Index means by health center characteristics (95% confidence interval) | ||||
| Planned Parenthood | 5.2 (5.0–5.4) | 10.4 (10.2–10.6) | 4.2 (3.9–4.4) | 7.3 (7.1–7.5) |
| Community health center | 4.3 (4.1–4.6) | 6.6 (6.3–6.9) | 1.5 (1.3–1.7) | 5.8 (5.7–6.0) |
| Health department | 4.9 (4.7–5.0) | 7.9 (7.7–8.0) | 3.7 (3.6–3.8) | 5.7 (5.6–5.8) |
| Hospital | 4.7 (4.2–5.1) | 7.5 (6.8–8.2) | 2.3 (1.7–2.9) | 5.5 (5.0–6.0) |
| Other provider | 4.9 (4.6–5.2) | 7.2 (6.9–7.6) | 2.7 (2.4–2.9) | 5.9 (5.7–6.1) |
| Received Title X funding | 5.0 (4.9–5.1) | 8.4 (8.3–8.6) | 3.7 (3.6–3.8) | 6.1 (6.0–6.2) |
| Did not receive Title X funding | 4.4 (4.2–4.6) | 6.7 (6.3–6.9) | 1.8 (1.6–2.0) | 5.7 (5.5–5.9) |
Each index is a simple, unweighted count index. Health centers missing responses for one or more items within an index were excluded from that index’s calculation.
Many respondents skipped these questions, so N values are reduced for this series compared to the others.
Ordered logistic regression results show that, compared to health departments, all health center types except the “other” category had significantly lower adjusted odds ratios (AORs) for the count index of the scope of family planning services provided frequently in the last 3 months. This means that those provider types were on average significantly lower on that index than health departments, controlling for the other health center characteristics listed (Table 4). For the count index of contraceptive methods provided onsite in the last 3 months, most health center types were similar to health departments, with the exception of Planned Parenthood centers, which had a large and significant AOR (7.31), indicating odds of being much higher on that index. For written contraceptive counseling protocols, Planned Parenthoods had increased odds of being higher on that index (AOR 1.82), compared to health departments, while community health centers had decreased odds (AOR 0.35;i.e., on average, they were lower on that index). For youth-friendly services, Planned Parenthood clinics, community health centers and other providers had increased odds of being higher on that index compared to health departments (3.48, 1.78 and 1.67, AOR, respectively).
Table 4.
AORs and 95% confidence intervals from ordered logistic regression of four indices of family planning services, among US publicly funded health centers providing family planning services, 2013–2014
| Index of the scope of family planning services provided | Index of contraceptive methods provided onsite | Index of contraceptive counseling written protocol | Index of youth-friendly services | |||||
|---|---|---|---|---|---|---|---|---|
| N=1360 | N=1280 | N=1168 | N=1297 | |||||
| Ref: Health department | ||||||||
| Planned Parenthood | 0.46*** | (0.33–0.63) | 7.31*** | (4.75–11.26) | 1.82** | (1.23–2.71) | 3.48*** | (1.43–4.97) |
| Community health center | 0.72* | (0.53–0.98) | 0.78 | (0.57–1.07) | 0.35*** | (0.24–0.50) | 1.78*** | (1.29–2.44) |
| Hospital | 0.52** | (0.34–0.81) | 0.64 | (0.39–1.04) | 0.54 | (0.29–1.02) | 1.12 | (0.67–1.86) |
| Other provider | 0.94 | (0.69–1.28) | 0.96 | (0.71–1.29) | 0.84 | (0.61–1.16) | 1.67** | (1.25–2.24) |
| Received Title X funding | 1.53** | (1.20–1.95) | 3.03*** | (2.30–3.98) | 2.71*** | (2.03–3.62) | 1.91*** | (1.47–2.47) |
| Ref: Mainly urban/suburban | ||||||||
| Mainly rural | 0.52*** | (0.39–0.68) | 0.53*** | (0.39–0.71) | 0.81 | (0.58–1.13) | 0.85 | (0.64–1.11) |
| Mix of rural, urban/suburban | 0.65** | (0.49–0.86) | 0.53*** | (0.39–0.73) | 0.88 | (0.62–1.25) | 1.04 | (0.77–1.39) |
| Ref: Northeast/Mid-Atlantic region | ||||||||
| South/Southwest | 0.78 | (0.58–1.05) | 0.74 | (0.55–1.02) | 1.76** | (1.24–2.50) | 0.78 | (0.59–1.04) |
| Midwest | 0.77 | (0.55–1.06) | 0.65** | (0.47–0.89) | 1.15 | (0.81–1.61) | 0.91 | (0.66–1.25) |
| Western | 0.72* | (0.53–0.97) | 1.16 | (0.83–1.64) | 1.11 | (0.78–1.58) | 0.72* | (0.53–0.98) |
| Total number of all clients seen in last yeara | 1.09 | (0.98–1.21) | 1.11 | (0.98–1.25) | 0.85* | (0.74–0.96) | 1.03 | (0.92–1.15) |
| Total number family planning clients seen last yeara | 1.75*** | (1.54–1.99) | 1.68*** | (1.46–1.94) | 1.23** | (1.06–1.43) | 1.39*** | (1.22–1.60) |
Each outcome is a simple count index of specific services or content. Family planning services provided is comprised of 9 items; contraceptive methods, 11 items; contraceptive counseling protocol content, 5 items; and youth-friendly services, 10 items. Health centers missing responses for one or more items within an index were excluded from that index.
p<.05.
p<.01.
p<.001.
Included as 6- and 5-part categorical variables, respectively.
Receipt of Title X funding was significantly associated with scoring higher on all four indices (AOR ranging from1.53 to 3.02). Serving rural areas — whether in addition to urban/suburban areas or not — was associated with scoring lower on the indices of family planning services and contraceptive methods provided, compared to serving mainly urban/suburban areas. However, the type of area served was not associated with the content of contraceptive counseling protocols or youth-friendly services. Geographic region of the country had some significant associations with three of four indices, but there was no evident pattern to those associations. Finally, increasing volume of annual family planning clients was associated with higher counts on all four indices (AOR ranging from 1.23 to 1.75, p<.01 in all cases), while the total number of patients of any kind was not independently associated with three of four indices.
4. Discussion
Many aspects of the services assessed were consistent with QFP’s high standards and recommendations, but there was evident room for improvement across aspects and types of health centers. Overall, we identified baseline strengths in some areas, such as for a number of youth-friendly services provided, onsite provision of numerous contraceptive methods and frequent provision of contraceptive and STD screening services. Other studies that focused on onsite availability of individual contraceptive methods (vs. provision) found similar patterns of results [8,9]. Another study of youth-friendly services at publicly funded health centers also found relatively positive findings in terms of confidentiality practices, accessibility, outreach and staff training aspects measured [10].
We identified a number of areas for overall improvement, including the content of written counseling protocols, and in the provision of the full range of family planning services recommended by QFP, particularly preconception health care, basic infertility services and services for males. The absence of written protocols outlining specific counseling practices does not necessarily mean that the counseling provided at that center was low quality. However, having high standards described in written clinic protocols can help ensure high-quality care and more consistent practices across staff [11]. The lower figures for preconception health care may be due to a lack of common understanding of what we meant by preconception health care in the survey [12]. Moreover, lower client demand for basic infertility services and smaller percentages of male clients seeking these family planning services partially accounts for lower prevalence of providing those services. Nevertheless, because QFP defines family planning services to include those specific types of services and highlights providing family planning services to males, we might expect to see increases on these measures in the future.
Consistent with other studies, we found that Title X funding was associated with being higher on all four service indices in multivariable analysis [9,10,12,13]. Title X-funded health centers may be more competitive to obtain grants under the Title X program in the first place, but another explanation could relate to the requirements and support provided to awardees under the Title X program on many of these issues. However, Title X-funded centers did not exceed in all areas; the bivariate analysis pointed to a few individual items for which Title X centers lagged non-Title X funded centers (e.g., in offering same-day appointments for clinical services).
Compared to other health center types, Planned Parenthood centers generally were higher on most items across the four aspects of service delivery. This finding was supported further in the multivariable analysis, which found that Planned Parenthood centers were higher on three or four indices compared to other types of health centers, when controlling for other health center characteristics. There was one exception in that those centers were lower than health departments for the index representing the scope of family planning services provided frequently in the last 3 months due primarily to less frequent provision of preconception health services. However, a separate analysis of these data found that, compared to other types of health centers, Planned Parenthood centers had higher odds than other types of health centers of having written protocols recommending 12 specific preconception health screenings (e.g., intimate partner violence, substance use) [12].
Community health centers were often about average or trailed other health center types on the items assessed. They were lower than the sample average for many of the family planning services provided frequently in the last 3 months. They also were lower than the sample averages for recent onsite provision of most contraceptive methods and substantially lower in terms of having particular content in their written contraceptive counseling protocols. In terms of youth-friendly services, community health centers exceeded most other health center types in some ways, such as offering same-day appointments, but were relatively lower on some other items. Given the large and increasing number of patients that community health centers serve, improvements in that sector in particular could yield significant gains in family planning outcomes [8,13,14].
Health departments presented a more mixed picture. They fared relatively well in terms of their written protocols for contraceptive counseling, but they notably lagged in the frequent delivery of basic infertility services and family planning services to men. Onsite provision of LARC was relatively low across health departments in this sample, though for many other contraceptive methods, health departments were close to or above the sample average. Similar for youth-friendly services, health departments did relatively well on some items but were lower than other health center types to have offered weekend or evening hours, same-day appointments and websites for patients to make appointments. Many health department clinics may have faced particular administrative and budget constraints to offering those options that require major changes or additions to program infrastructure. Hospitals and other health center types also presented more mixed pictures in these data, with strengths in some areas (e.g., hospitals’ onsite provision of LARC) and apparent weaknesses in others.
4.1. Limitations
“Quality” is a broad concept involving multiple dimensions, and our findings only captured some aspects of that. Extensive assessment of health centers’ infrastructure, protocols, clinician practices and patient experiences would be needed to fully assess alignment with QFP recommendations and the quality of care. This survey also asked about the provision of some services or methods in the prior 3 months, as opposed to the availability of those. Provision relies not only on service infrastructure and supply but also patient demand for those services. All results were self-reported by health center administrators or clinic staff and prone to desirability and recall bias. A large proportion of respondents skipped the questions about the content of their written contraceptive counseling protocol, and we excluded from the index analysis health centers that were missing on any single item in that index. Finally, the survey response rate was about 50%, which is clearly suboptimal but on par with surveys of this kind [10,13].
4.2. Conclusion
Many factors contribute to differences in service profiles among types of health center and between individual clinics, ranging from funding sources, government policies and organizational policies to staffing plans and patient characteristics. Future studies should delve more deeply into the nature and causes of variation observed in these data. Making improvements across these various aspects of service delivery is also complex. The evidence on knowledge translation and implementation science shows that active efforts to support implementation of QFP among health centers are needed, alongside monitoring and evaluation to document progress and understand unique barriers and facilitators of implementation [15,16]. Such investments are likely worthwhile. Making improvements to the scope and quality of family planning services offered in all health centers that provide those services (publicly funded or not) would be in the interest of the triple aim of better family planning outcomes, increased patient satisfaction and reduced costs.
Acknowledgements
The findings and conclusions of this report are those of the authors and do not necessarily represent the official position of the CDC or the OPA.
Footnotes
Conflicts of interest: None.
Preconception health care is the medical care a woman or man receives that focuses on the parts of health that have been shown to increase the chance of having a healthy baby (e.g. support for smoking cessation; blood pressure control) http://www.cdc.gov/preconception/overview.html.
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