Specialized family planning clinics in the United States: why women choose them and their role in meeting women's health care needs.

BACKGROUND: Publicly funded family planning clinics provide contraceptive care to millions of poor and low-income women every year. To inform the design of services that will best meet the contraceptive and reproductive health needs of women, we conducted a targeted survey of family planning clinic clients, asking women about services received in the past year and about their reasons for visiting a specialized family planning clinic. METHODS: We surveyed 2,094 women receiving services from 22 family planning clinics in 13 states; all sites included in the survey were clinics that specialize in contraceptive and reproductive health services and were located in communities with comprehensive primary care providers. RESULTS: Six in 10 (59%) respondents had made a health care visit to another provider in the past year, but chose the family planning clinic for contraceptive care. Four in 10 (41%) respondents relied on the family planning clinic as their only recent source for health care. The four most common reasons for choosing a specialized family planning clinic, reported by at least 80% of respondents, were respectful staff, confidential care, free or low-cost services, and staff who are knowledgeable about women's health. CONCLUSIONS: Specialized family planning clinics play an important role as part of the health care safety net in the United States. Collaborations between such clinics and comprehensive primary care providers, such as federally qualified health centers, may be one model for ensuring women on-going access to the full range of care they need.

The public costs of births resulting from unintended pregnancies: national and state-level estimates.

CONTEXT: Births resulting from unintended pregnancies are associated with substantial maternity and infant care costs to the federal and state governments; these costs have never been estimated at the national and state levels. METHODS: The proportions of births paid for by public insurance programs in 2006 were estimated, by pregnancy intention status, using data from the Pregnancy Risk Assessment Monitoring System and similar state surveys, or were predicted by multivariate linear regression. Public costs were calculated using state-level estimates of the number of births, by intention status, and of the cost of a publicly funded birth. RESULTS: In 2006, 64% of births resulting from unintended pregnancies were publicly funded, compared with 48% of all births and 35% of births resulting from intended pregnancies. The proportion of births resulting from unintended pregnancies that were publicly funded varied by state, from 42% to 81%. Of the 2.0 million publicly funded births, 51% resulted from unintended pregnancies, accounting for $11.1 billion in costs-half of the total public expenditures on births. In seven states, the costs for births from unintended pregnancies exceeded a half billion dollars. CONCLUSIONS: Public insurance programs are central in assisting American families in affording pregnancy and childbirth; however, they pay for a disproportionately high number of births resulting from unintended pregnancy. The resulting budgetary impact warrants increased public efforts to reduce unintended pregnancy.

Role of medicaid family planning waivers and Title X in enhancing access to preconception care.

PURPOSE: This article identifies the ways in which Medicaid eligibility expansions for family planning services and the Title X network of family planning clinics provide opportunities to introduce preconception care. The introduction of family planning eligibility expansions brought in populations heretofore ineligible for Medicaid. Family planning clinics serve a large number of low-income and young women and would play an important part in introducing preconception care. However, very real barriers to preconception service provision need to be addressed before this goal can be fully realized. BACKGROUND: When established in 1965, Medicaid, by and large, covered low-income women and their children receiving welfare. A succession of Medicaid eligibility expansions for pregnancy-related care broke the link with welfare. More recently, expansions implemented in 20 states have created an eligibility pathway to Medicaid coverage for women before pregnancy. Today, whether as part of a Medicaid family planning program or independently, many women receive family planning services through the nation's system of publicly funded clinics. As the nation's only dedicated source of funding for family planning services, Title X supports a nationwide network of family planning clinics on which young women rely for affordable and confidential reproductive care. DISCUSSION: Working preconception care into the existing family planning and pregnancy care programs would create a single, continuous reproductive health care platform. Family planning clinics could introduce preconception health measures to the young women who rely on them for their reproductive health care. Important barriers to rolling out preconception care still exist, however. For family planning providers to integrate the services into their current practices, a definition of the package of services that is realistic to provide in a family planning setting must be crafted. In addition, securing a stable funding stream is a necessary prerequisite to any large-scale integration of preconception care into family planning settings. Finally, attention needs to be given to ways to talk to predominantly young clientele about preparing for a pregnancy at the moment when they are coming in for services precisely to avoid becoming pregnant. CONCLUSION: Despite the challenges laid out, integrating preconception care into family planning services is achievable. Combining preconception care with family planning and pregnancy care initiatives would be a significant step in moving the country closer to the goal of providing the comprehensive reproductive health care women need.

U.S. insurance coverage of contraceptives and the impact of contraceptive coverage mandates, 2002.

CONTEXT: In 1993, coverage of reversible contraception by U.S. health insurance plans was extremely low. Little is known about how coverage has changed since then, particularly in response to state mandates. METHODS: In 2001-2002, a nationally representative sample of 205 health care insurers responded to a survey about coverage of reproductive health care services in "typical" employment-based managed care plans (excluding self-insured plans). Data were analyzed to compare coverage in states with and without contraceptive coverage mandates, and to show trends in coverage between 1993 and 2002. RESULTS: In 2002, almost every reversible contraceptive service and supply studied was covered by at least 89% of typical plans; 86% of plans covered the five leading prescription methods (the diaphragm, one- and three-month injectables, the IUD and oral contraceptives). Coverage of each contraceptive service and supply studied was higher in 2002 than in 1993 (78-97% vs. 32-59%). Plans in states with mandates were significantly more likely to cover the five leading prescription methods (87-92%, depending on type of plan) than were those designed locally in states without mandates (47-61%). Between 1993 and 2002, state mandates were estimated to account for 30% and 40% of the increase in coverage of oral contraceptives and the three-month injectable, respectively. CONCLUSIONS: Coverage of reversible contraception--and by extension, choice within a range of covered methods--has increased substantially since 1993, in part because of state mandates. This state-by-state approach, however, has inherent limitations that can best be dealt with at the federal level.

Overhauling welfare: implications for reproductive health policy in the United States.

The overhaul of the welfare system in 1996 broke the historic link between eligibility for welfare benefits and eligibility for Medicaid, ended a longstanding requirement that welfare recipients be given access to family planning services, and, at the same time, included a number of controversial features directed at reducing out-of-wedlock childbearing and promoting abstinence-only education. Five years later, the number of women enrolled in Medicaid is down, the number not covered by insurance is up, and abstinence-only education has become a prominent feature of the government's effort to decrease the incidence of out-of-wedlock pregnancies. Very little is known about how well these interventions are working and what impact, positive or negative, they have had. As Congress heads for reauthorization of the nation's welfare law later this year, policy makers should give increased attention to the provision of information and services, including those related to family planning, in order to better address the reproductive health needs of low-income women.