Family Planning Clinic Services In the United States, 1994
In 1994, almost 6.6 million women received contraceptive services from more than 7,000 subsidized family planning clinics; these providers were located in 85% of U.S. counties. Health department clinics and Planned Parenthood sites served the largest proportions of these women (32% and 30%, respectively), followed by hospital outpatient sites (16%), independent clinics (13%) and community or migrant health centers (9%). The mix of agency types varied considerably by region and state, and the average annual number of contraceptive clients served per clinic also varied from fewer than 500 at community and migrant health centers to more than 2,000 at Planned Parenthood clinics. Nearly two-thirds of all women served (4.2 million) obtained care at one of the 4,200 clinics receiving funds from the federal Title X family planning program. Health department sites were the most likely to receive Title X funding (78%), followed by independent clinics and Planned Parenthood sites (66% each), hospital clinics (28%) and community and migrant health centers (18%). Overall, clinics receiving Title X funds serve an average of 25% more contraceptive clients than do clinics not receiving such funds.
(Family Planning Perspectives, 28:92-100, 1996)
For two and a half decades, the network of family planning clinics in the United States has played a critical role in ensuring access to contraceptive services for millions of women: Of all women making a family planning visit, 36% receive services from a family planning clinic. Among women seeking family planning services, the percentage who obtain care from clinics rises to 60% of women whose family income is below the federal poverty level and to 62% of women younger than 20. 1
Women have numerous reasons for seeking family planning services from clinics rather than from private physicians. For many women, the primary reason is financial.2 Clinics are subsidized by federal, state, local o r private funds, and many offer uninsured low-income women services free or at reduced fees. In addition, many insured women do not have coverage for contraceptive services, drugs or devices.3
Clinics usually charge these women less than a private physician would charge for services and methods. Moreover, clinic providers are more likely than private physicians to accept Medicaid (83% vs. 73%).4 In addition, clinic providers are more likely than private physicians to be located in the areas where low-income women live. Finally, family planning clinics are often perceived by women as providing greater confidentiality (a factor that is particularly important to teenage women) than might otherwise be possible when services are provided by a doctor who serves their entire family.5
The universe of subsidized family planning clinics in the United States was last fully described for the year 1983.6 A total of 2,462 agencies with operating responsibility for 5,174 family planning clinics were identified and data were collected on the numbers and characteristics of women receiving contraceptive services (including age, poverty status, race and contraceptive methods used) from these sites. In 1992, the universe was updated and found to contain 2,614 agencies with operating responsibility for between 5,460 and 5,960 family planning clinic sites. At that time, data on client numbers and agency policies and procedures were collected from only a sample of agencies. 7
Thus, since 1983, there has not been a thorough enumeration of the network of family planning providers and the women who receive care from them. Such an enumeration is critical now. As the level of funding and structure of the programs that currently subsidize family planning clinics (Title X, maternal and child health and social services block grants, Medicaid and others) are being reevaluated, current data on the women and clinics dependent on these funding sources are needed to ensure that vital services are not lost in the process.
Subsidized family planning providers depend on a variety of funding sources to sustain their programs. One of the most important of these sources is the Title X program of the Public Health Service Act, which is the only federal program specifically designed to provide funding for family planning services. In 1992, this program provided family planning clinics with more than $110 million to provide contraceptive services to low-income women in the United States.8 Current expenditures are undoubtedly higher, given that congressional appropriations for Title X rose by more than 20% between 1992 and 1994. Although the impact of potential changes in this program, such as shifting its funds into block grants or consolidating it with other public health programs, remains uncertain,9 the data provided in this study document how many millions of women and thousands of clinics nationwide stand to be affected by such changes.
A second important source of federal funding for family planning agencies is Medicaid. Although this program provided nearly $320 million in 1992 for the provision of contraceptive services,10 the proportion of these funds that went to family planning clinics and agencies rather than to private physicians is unknown. In 1992, more than 80% of all family planning agencies received some income from Medicaid; however, the average amount of income received per agency was only about one-third the amount received from the Title X program.11 Changes in Medicaid, particularly shifts toward Medicaid managed care, would affect family planning agencies and clinics, as well as the women who receive care from these sites.
Finally, family planning clinics receive significant amounts of funding from other public and private sources. State funding, for example, has become an increasingly important source of support: In 1992, more than $150 million in state monies was used for the provision of contraceptive services,12 and 69% of all family planning agencies in the 1992 survey reported receiving state funds.13
This article provides an updated enumeration of all subsidized family planning clinics nationwide and of the numbers of women and teenagers who obtained contraceptive services from these clinics in 1994. In addition to clinics that receive federal funds to provide family planning services through the Title X program, we have counted clinics that receive other public and private subsidies, such as hospital outpatient clinics, community and migrant health centers and independent clinics. Thus, the universe of clinics reported on has been broadened from that of previous studies to more fully describe the types and distribution of family planning clinics that are used by low-income women.
This study is based on data gathered from agencies and clinics providing subsidized family planning services in the United States and its jurisdictions. Family planning agencies are defined as organizations that have operating responsibility for clinics in which contraceptive counseling, education and services are provided. * Agencies are included in this universe only if they provide contraceptive services to the general public and if they provide services to at least some of their clients for free or at a reduced fee or if they are subsidized by public funds (including Medicaid).
Most of the clinics included here provide comprehensive medical contraceptive services. A few of the included sites, however, provide counseling and education and dispense only nonmedical methods of family planning (e.g., natural family planning or periodic abstinence). Private physicians' offices and group practices are excluded, as are health care centers that serve restricted populations, such as facilities run by health maintenance organizations, college and school health centers, and facilities providing care to veterans or military personnel.
Although the broad definition of agencies providing organized family planning services has remained similar in all our studies, the definition used in 1994 differs in two important ways from that used in 1983 and 1992. First, the definition of and process for including community and migrant health centers** and hospital outpatient clinics were expanded to reflect more accurately the important role that these agencies play in providing contraceptive care to low-income women. Thus, the large increase in the numbers of such agencies in 1994 relative to other years does not indicate that many new agencies have opened. In previous studies, we included community and migrant health centers only if they received Title X funds, but in this study, we include all agencies receiving community or migrant health center funding that reported providing contraceptive services. Likewise, a systematic investigation of the provision of contraceptive services through hospital outpatient clinics was carried out as the universe of family planning clinics was updated, resulting in the addition of many "new" hospital providers.
Second, the universe of family planning providers has been broadened to include agencies and sites providing services to women in eight U.S. jurisdictions (American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Mariana Islands, Puerto Rico, Palau and the Virgin Islands).
To create the 1994 universe of family planning agencies and, at the same time, gather information about the numbers of contraceptive clients served at every clinic in the nation, we first obtained current lists of family planning agencies and sites from all Title X grantees and state family planning administrators. Using these lists and the directory of Title X-funded agencies and clinics published by the Department of Health and Human Services,14 we updated our 1992 data file with current information. We then added all community and migrant health centers listed in the 1994 Primary Care Programs Directory;15 any added agencies that responded negatively to our inquiries about provision of contraceptive services were eliminated at a later stage.
Finally, we telephoned more than 2,700 hospitals identified in the 1994 American Hospital Association Guide16 as providing "reproductive health services" or "women's health services." Of these, 276 were already included in the file. An additional 295 hospital agencies providing subsidized contraceptive services were identified and added to the file.
Using the updated data file, we created a list of all known agencies and clinics for each state. These lists were mailed to 84 Title X grantees (including 37 who are also state family planning administrators and five who are family planning administrators for the District of Columbia, Puerto Rico, Virgin Islands, American Samoa and Guam), as well as 13 state family planning administrators who are not Title X grantees. We asked respondents to provide agency or clinic updates and information on the Title X funding status of each site, as well as the total number of female contraceptive clients served per site in 1994 and the number of female clients served who were younger than 20. Overall, Title X grantees and state family planning administrators provided client data for 4,574 clinics, representing 64% of all sites and 73% of all sites for which we obtained client data.
To collect similar client data from agencies that do not report to a Title X grantee or a state family planning administrator, we mailed surveys to more than 1,500 hospitals, community and migrant health centers and independent agencies. These agencies were believed to be administering over 2,500 clinic sites. Ninety health department agencies for whom states could not supply data also received individual mailed requests. Each agency received up to three mailed requests. Finally, all agencies that did not respond to multiple mailings were telephoned to confirm their eligibility and were then faxed a final request for client data.
As a result of these efforts, 596 family planning agencies, representing 1,372 clinics, independently reported data in response to our mailed requests, and an additional 135 agencies, representing 263 sites, provided data in response to our final telephoned and faxed requests. We obtained data for 74 clinics from a separate survey in which a sample of family planning agencies were asked to complete a 16-page survey covering many different aspects of agency policy and services.
Although we tried to be as explicit as possible about which clients should be reported as contraceptive clients, some agencies were unable to provide precise data. Some respondent agencies (particularly hospitals and community or migrant health centers) reported that their recordkeeping procedures made it impossible to separate contraceptive clients from other clients; however, they were able to provide estimates of the number of contraceptive clients served.
In other cases, only the total number of contraceptive clients for the entire agency was reported. These agencies were followed up by phone to try to determine the approximate percentage distribution of clients by site. If agencies could not provide any further assistance in distributing clients by site, the agency totals were distributed evenly among all sites. The client numbers for 6% of sites are based on agency totals using this distribution methodology. In two-thirds of these cases, totals were distributed among sites located within one county.
Finally, although respondents were asked to report client numbers for calendar year 1994, the data provided for 6% of sites covers a different reporting period than the one requested. In most cases, agencies reported fiscal year data for a 12-month period that covers at least a portion of calendar year 1994.
All reported numbers of clients were checked, edited, entered and verified. In many instances, telephone follow-up was necessary to clarify responses and confirm the closing or opening of additional sites reported. The final file of family planning clinics actively providing contraceptive services in 1994 consists of 3,119 family planning agencies and 7,122 clinics operated by these agencies.
In total, agencies reported or estimated the number of female contraceptive clients for 88% (6,283) of all family planning clinics. Some of the agencies that did not provide data responded that the client information was unavailable and that they were unable to provide even an estimate of client numbers. Other agencies simply failed to respond to our multiple mailings and faxed request, although all agencies that were included in our tabulations and lacked client data were contacted by phone to confirm their status as providers.
To estimate the total number of clients served by all sites, we imputed client numbers for the 839 clinics for which agencies did not provide data. Most of these sites were either hospitals (344 sites) or community or migrant health centers (342 sites) that were not funded through Title X. First, using all sites with reported client numbers, we calculated the average number of clients served per site according to region of the country, provider type, Title X funding status and location within a metropolitan or nonmetropolitan county. The estimation of client numbers for hospital sites was further refined to include capacity (fewer than 200 beds or at least 200).
Sites without data were then assigned the average number of clients served by other sites located in the same region and of the same provider type, Title X funding status and type of location (and capacity group for hospital clinics). For example, if client numbers were not available for a community health center in the West that did not receive Title X funding, this site was assigned the mean number of contraceptive clients served at all other such sites in the West.
FAMILY PLANNING PROVIDERS
The number of subsidized family planning agencies surveyed increased by nearly 20% between 1992 and 1994: The number of hospital agencies is more than 100% larger and the number of community and migrant health centers is 45% larger. However, as explained in the methodology, this increase is due primarily to a more inclusive definition. The number of health department agencies remained virtually constant between 1992 and 1994, and the number of Planned Parenthood affiliates declined slightly because of consolidation.
The number of independent family planning agencies, however, rose by more than 25%, a substantial increase. While some of this change may stem from the reclassification of other provider types as independents, much of the increase represents agencies reported for the first time by state family planning administrators and Title X grantees. Many of these newly added independent agencies are recently opened local women's or family health clinics, community action agencies and free clinics.
Even with the wider inclusion of hospitals and community and migrant health centers, the network of subsidized family planning agencies continues to be dominated by health departments. In 1994, more than 1,400 health departments were providing subsidized family planning services, accounting for 45% of the entire universe (Table 1). Hospitals, community and migrant health centers, and independent agencies each made up about 16-17% of the total, while Planned Parenthood affiliates accounted for only 5% of all agencies.
|Table 1. Numerical and percentage distributions of subsidized U.S. family planning agencies and clinics, by type of provider, according to funding and location, 1994|
|Funding and location||Type of provider|
|All types of funding|
|Title X funding (1994)|
|Any site funded||1,868||100.0||1,232||66.0||112||6.0||98||5.2||300||16.1||126||6.7|
|All sites funded||1,643||100.0||1,136||69.1||94||5.7||69||4.2||276||16.8||68||4.1|
|Title X funding||4,202||100.0||2,444||58.2||221||5.3||216||5.1||703||16.7||618||14.7|
|Metropolitan counties||3,789||100.0||1,294||34.2||610||16.1||< td align="right">676||17.8||534||14.1||675||17.8|
|*Between 1992 and 1994, the definition of and process for including hospital outpatient departments and community or migrant health centers changed. Thus, the increase in numbers of hospital and community/migrant health center agencies does not represent newly opened agencies, but rather a decision to include previously excluded agencies.|
Health departments were also the provider type most likely to be recipients of Title X funding in 1994, with almost nine in 10 receiving some funds through the program (not shown). Nearly eight in 10 Planned Parenthood affiliates and six in 10 independent agencies also received some Title X funding. However, only about two in 10 hospital and community or migrant health center agencies providing family planning services received Title X funds. This low level of funding is not surprising for community and migrant health centers, given that such agencies are required to provide their clients with a full range of primary care services, including family planning, regardless of whether they receive additional family planning funds.
Although 1,868 family planning agencies received some Title X funding in 1994 to provide contraceptive services, only 1,643 (88%) of those agencies received Title X funding for all of their clinics. Large proportions of health departments, hospitals and independent agencies funded through Title X received funds for all their clinics (84%-92%). In contrast, only 70% of Title X-funded community or migrant health center agencies and 54% of funded Planned Parenthood affiliates received funding for all of their clinics.
In 1994, these family planning agencies provided services at more than 7,000 clinics nationwide and within U.S. jurisdictions (Table 1, panel 2). Again, although this number is 38% higher than the 5,174 reported in 1983,17 the increase is due primarily to changes in how family planning clinics were defined and not to large numbers of newly opened sites. The distribution of clinics by type of provider is similar to the distribution of agencies, with the exception of Planned Parenthood clinics and hospital sites. While only 5% of all agencies are Planned Parenthood affiliates, 13% of all clinics are operated by these agencies; conversely, hospitals make up 17% of agencies, but account for only 11% of clinics.
These differences can be explained by variations in the average number of clinics operated per agency. Among health departments, community and migrant health centers and independent agencies, the average number of clinics per agency is slightly more than two. However, Planned Parenthood affiliates operate an average of nearly six clinics per agency, while hospitals have an average of only 1.5 clinics.
Slightly more than half (53%) of all clinics are located in metropolitan counties. Approximately three in four hospital sites and Planned Parenthood clinics are located in metropolitan counties, while almost three in five health department sites are in nonmetropolitan counties. Community and migrant health center sites and independent agency sites are about evenly divided between metropolitan and nonmetropolitan counties.
In 1994, an estimated 6.6 million women received contraceptive services through the network of subsidized family planning providers (Table 2), a 30% increase over the nearly five million women served at family planning clinics in 1983.18 Again, much of this increase is due to changes in how clinic providers were defined, particularly the inclusion of publicly funded clinics that are not part of the Title X universe. Among all women served, 4.8 million received family planning services at clinics operated by agencies receiving Title X funds, and 4.2 million were served at clinics actually receiving Title X funds. This latter number is virtually identical to the number of women served at Title X-funded clinics in 1991.19
|Table 2. Number (in 000s) and percentage distributions of clients served at family planning clinics, by type of provider, according to selected characteristics of clients, and average number of clients served per agency and site, by type of provider|
|Characteristics of clients||Type of provider|
|and type of site|
|Distribution of clients|
|Served at Title X site||4,221||100.0||1,846||43.7||336||8.0||122||2.9||643||15.2||1,275||30.2|
|Average no. of clients|
|Title X site||1,005||na||755||na||1,522||na||563||na td>||915||na||2,063||na|
|Non-Title X site||805||na||414||na||1,240||na||478< td>na||62||na||2,094||na|
|Note: na=not applicable.|
Health department and Planned Parenthood clinics served the largest percentages of women (32% and 30%, respectively), followed by hospitals (16%), independent agencies (13%) and community and migrant health centers (9%). These figures allow us to compare the distribution of clients served according to the type of provider from whom services were received to the distribution of clinics by provider type shown in Table 1.
The wide variation between the distribution of clinics and clients served by provider type reflects substantial differences in the average number of women served per site at different provider types (Table 2). Among all agencies, the average number of women served in 1994 exceeded 2,000 per agency, with an average of 923 clients served per clinic. Planned Parenthood affiliates served significantly more clients, with an average of more than 12,000 contraceptive clients per agency and more than 2,000 per clinic. The large numbers of contraceptive clients served per Planned Parenthood clinic explains how a provider type that represents only 5% of all family planning agencies and 13% of all clinics can serve 30% of all women. In contrast, community and migrant health centers averaged fewer than 500 contraceptive clients per clinic.
Nearly 30% of all women served (1.8 million) were younger than 20. This percentage varies somewhat by provider type, with hospitals and community and migrant health centers having the highest percentage of teenage clients (30%, or 312,000 of one million clients and 181,000 of 601,000 clients, respectively) and Planned Parenthood clinics having the lowest percentage (26%).
The 4.2 million women who obtained contraceptive care in 1994 from Title X-funded clinics represent nearly two-thirds of all women served (64%) by subsidized family planning providers. Like the proportions of clinic sites with Title X funding, the proportions of women served at Title X-funded sites vary greatly according to provider type. Only one in five women receiving contraceptive services from community and migrant health centers (122,000 of 601,000) and one in three women obtaining care from hospital sites (336,000 of one million) attended sites funded through the Title X program. On the other hand, two in three of Planned Parenthood's contraceptive clients, three in four women obtaining contraceptive services from independent agencies and nearly nine in 10 women obtaining contraceptive care from health department sites received services from Title X-funded sites.
On average, clinics receiving Title X funding served at least 25% more clients per site than did those not receiving such funding (1,005 compared with 805). In fact, health department sites receiving Title X funds served, on average, nearly twice as many contraceptive clients as did those without Title X funding. On the other hand, the average number of clients served at Planned Parenthood clinics varied little by whether the sites received Title X funds.
Although the number of family planning clinics in metropolitan and nonmetropolitan counties is roughly the same (Table 1), the distribution of contraceptive clients is heavily weighted toward metropolitan counties. Reflecting the overall population distribution of women between metropolitan and nonmetropolitan counties, 74% of all women served by subsidized family planning providers (4.9 million of 6.6 million, as shown in Table 2) received services at sites located in metropolitan counties. Thus, provider types that are more likely to have sites in metropolitan counties (hospitals and Planned Parenthood affiliates) also serve a mostly metropolitan clientele, with nearly 90% of all contraceptive clients seen by these providers served at sites located in metropolitan counties. Moreover, even provider types that have disproportionately higher numbers of sites in nonmetropolitan areas (health departments, community and migrant health centers and independent agencies) serve most of their clients in metropolitan counties.
The distribution of clients served by provider type within metropolitan and nonmetropolitan counties (Table 2) shows that hospitals and Planned Parenthood clinics together account for 54% of the clients served in metropolitan counties, while health departments account for 24% of all clients served in such counties. Conversely, health departments serve 55% of all clients in nonmetropolitan counties, while hospitals and Planned Parenthood clinics together serve only 20%. Finally, since metropolitan counties by definition have a higher population density, it is not surprising that sites in such counties serve on average more than twice the number of clients served at sites in nonmetropolitan counties (1,290 vs. 505).
• All clients. The proportion of clients served by different types of family planning providers in 1994 varied by region of the country (Table 3). For example, the percentage of contraceptive clients served by health department sites ranged from only 1% of all contraceptive clients in the northeastern states (Region I) to 71% in the southeastern states (Region IV). In the eastern states (Regions I, II and III), hospital clinics served relatively greater proportions of women (23-28%) than did hospital clinics in other regions (9-19%). Planned Parenthood sites served more than 40% of all contraceptive clients in the midwestern states (Region V), but only 9% of clients in the southeastern states (Region IV).
|Table 3. Estimated number of family planning clients and of clients younger than 20, percentage distribution by type of provider, and percentage of clients served at Title X-funded clinics, all according to region|
|Client group||No.||Provider type||% served|
|and region||Total||Health||Hospital||Community/||Indepen-||Planned||at Title X-|
|Note: The 10 U.S. regions are constituted as follows: Region I—Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island and Vermont; Region II—New Jersey, New York, Puerto Rico and the U.S. Virgin Islands; < b>Region III—Delaware, District of Columbia, Maryland, Pennsylvania, Virginia and West Virginia; Region IV—Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina and Tennessee; Region V—Illinois, Indiana, Michigan, Minnesota, Ohio and Wisconsin; Region VI—Arkansas, Louisiana, New Mexico, Oklahoma and Texas; Region VII—Iowa, Kansas, Missouri and Nebraska; Region VIII—Colorado, Montana, North Dakota, South Dakota, Utah and Wyoming; Region IX—Arizona, California, Hawaii, Nevada, American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Mariana Islands and Palau; Region X—Alaska, Idaho, Oregon and Washington.|
In most regions, 60-70% of all contraceptive clients were served at Title X-funded sites (Table 3, last column). In the middle Atlantic and southeastern states (Regions III and IV), the proportion of clients attending Title X-funded clinics was even higher (77% and 75%, respectively), while in the northwestern states (Region X) that proportion was only 57%. These regional differences are related to the actual number of Title X-funded sites within different states relative to the total number of subsidized providers of contraceptive services. The proportions of all sites that are Title X-funded varies greatly among states: For example, fewer than 30% of all sites are funded through Title X in Alaska, Arizona and Utah, compared with more than 85% of all sites in Arkansas, Georgia, Kentucky and West Virginia (not shown).
• Teenage clients. In every region, 22-32% of all contraceptive clients were younger than 20. The proportions of teenage clients were highest in the Southeast, Midwest and Central regions (30-31%) and lowest in the West (22%). These data do not reveal whether such differences relate to variations in the actual percentages of teenagers obtaining contraceptive services from any source or to variations in the propensity of both teenagers and older women to obtain services from subsidized family planning providers rather than other types of providers. The distribution of teenage clients according to provider type and region is quite similar to the distribution for all women. Slight differences can be found in the northeastern (Region I) and central states (Region VII), where hospitals serve a higher percentage of teenagers than of all women (30% vs. 23% and 19% vs. 14%, respectively).
COVERAGE OF U.S. COUNTIES
In 1994, more than 85% of all U.S. counties had at least one clinic providing subsidized family planning services, and nearly three-quarters had at least one Title X-funded provider (Table 4). In 18 states, every county had at least one subsidized provider and in 13 states, every county had at least one Title X-funded provider. However, in the other states, the provision of services was less complete. In five states (Alaska, Montana, Nebraska, North Dakota and South Dakota), more than 40% of all counties lacked a clinic providing subsidized family planning services. In these same states, with the exception of Montana, more than three-quarters of all countries lacked a Title X-funded provider. Furthermore, in an additional six states (Indiana, Minnesota, Missouri, Texas, Utah and Wisconsin), more than 50% of all counties lacked a Title X-funded provider.
|Table 4. Number of counties, percentage without family planning clinic and percentage without Title X-funded clinic, by state|
|State||All||No||No Title X|
|District of Columbia||1||0.0||0.0|
|*In Minnesota, 10 of the 24 counties without any clinic providers have private physicians that subcontract with family planning agencies to provide subsidized family planning services to women in the county. Note: Information on numbers of counties and the locations of clinics within counties for U.S. jurisdictions was unavailable when this analysis was conducted.|
Table 5 (page 98) categorizes counties according to the estimated number of women at risk of an unintended pregnancy who are in need of subsidized family planning care. The estimates used are for 1990, the most recent data available. 20 By comparing the numbers of women served by subsidized family planning providers to the numbers of women in need of subsidized care, we can identify possible gaps in the provision of services.
|Table 5. Number of U.S. counties, number of clinics and percentage distribution by number of clinics per county, according to number of women in need of subsidized care|
|Number of||No. of women in need of subsidized care|
|and clinics per county||1,999||4,999||9,999||19,999|
|No. of counties||3,139||1,248||678||644||275||149||145|
|No. of clinics||7,054||1,176||983||1,196||746||691||2,262|
|No. of clinics per county|
|Notes: Some columns may not add to 100% because of rounding. Figures do not include counties in U.S. jurisdictions.|
However, the data presented here cannot be used to analyze time trends in the adequacy of family planning providers to meet the needs of low-income women because both the definition of family planning agencies and the definition of women in need have changed since our 1983 study,21 which presented similar data. In 1983, women in need were defined as women at risk of an unintended pregnancy whose household income was less than 150% of the federal poverty level. Because we have raised the income ceiling to 250% of poverty to match the Title X requirement that women with incomes below that level be served for free or on a sliding fee scale, comparisons between the two years are untenable.
As Table 5 shows, the counties with fewer than 1,000 women in need are the most likely to lack a subsidized family planning provider, with more than 30% of such counties unserved; very few counties with at least 1,000 women in need have no provider at all . As one would expect, the number of clinics per county increases with the number of women in need of services, and the majority of counties with more than 10,000 women in need have at least four clinics.
A comparison of the percentage distribution of all U.S. counties with the percentage distribution of all family planning clinics according to the size of the population in need of subsidized services (not shown) shows that nearly 40% of all U.S. counties have fewer than 1,000 women in need, and only 17% of all subsidized family planning clinics are in such counties. Conversely, 5% of all U.S. counties have 20,000 or more women in need, and 32% of all family planning clinics are in such counties. On average, the counties with the smallest populations of women in need have fewer than one clinic each, while those with the largest populations of such women have more than 15 clinics each.
A comparison of the distributions of clinics and women served by the number of women in need (not shown) demonstrates that although only 11% of women in need reside in counties with fewer than 2,000 women in need, more than 30% of all clinics are located in these counties. In contrast, nearly 50% of all women in need reside in counties with 20,000 or more women in need, but only 32% of clinics are in these counties.
A further look at the actual numbers of clinics and clients per 1,000 women in need of subsidized services according to the population of women in need (not shown) clarifies the importance of family planning clinics for counties with small populations of women in need. Overall, for every 1,000 women in need of subsidized services, there are an average of 0.5 family planning clinics and 431 clients served, and there are an average of 0.3 Title X-funded clinics with 276 clients served. Among counties with fewer than 1,000 women in need, there are 1.9 family planning clinics with 450 clients served for every 1,000 women in need and 1.2 Title X-funded clinics with 325 clients served. In contrast, in the counties with at least 20,000 women in need, there is only 0.1 family planning clinic with 419 clients served for every 1,000 women in need and 0.1 Title X-funded clinic with 227 clients served.
Finally, counties with fewer than 10,000 women in need depend on Title X funding to subsidize care for approximately 72-79% of clients and to support 62-68% of all clinics. However, these percentages drop to 54% of clients and 49% of clinics in the counties with the most women in need.
COVERAGE OF WOMEN IN NEED
Another way to assess the adequacy of the current network of family planning providers is to measure how well these providers are meeting the contraceptive needs of low-income women within different regions and states.
Table 6 shows the numbers of women served by family planning clinics in 1994 and the numbers of women in need of subsidized care by region and state. Not all women served were poor enough to meet the income definition of need, so the actual ratios of poor women served to women in need will be somewhat lower than these numbers indicate. However, at least at Title X-funded clinics, the percentage of women served with incomes above 250% of the poverty level is likely to be fairly small. In 1991, 84% of all clients served at Title X-funded clinics had incomes below 150% of the poverty level, and the proportion of the remaining women with incomes below 250% of the poverty level is unknown.22 Furthermore, the low-income women represented as "unserved" in these comparisons of states and regions might have obtained services from other providers not included in the universe of subsidized providers considered here (e.g., private physicians, managed care organizations and pharmacies), or they might truly have been unserved.
|Table 6. Estimated numbers of all women and of teenagers in need of subsidized contraceptive care, and the estimated number served by family planning clinics, by region and state|
|Region and state||All women*||Teenagers|
|In need||Served||Served at||In need||Served||Served at|
|at clinics||Title X clinics||at clinics||Title X clinics|
|District of Columbia||44,890||25,660||14,540||13,130||8,120||4,840|
|U.S. Virgin Islands||u||3,010||3,010||u||470||470|
|Note: u=unavailable. *Women aged 20-44 who are at risk of an unintended pregnancy and whose income is less than 250% of the federal poverty level, plus all women younger than 20 who are at risk of an unintended pregnancy. Estimated for 1990.|
The highest proportions of women served were in the northeastern, central and northwestern states (Regions I, VII and X), with 48-51% of all women in need served. On the other hand, 41% or fewer of women in need in the midwestern and midsouthern states (Regions V and VI) were served.
At the state level, these differences are even more pronounced. For example, in eight states (Alaska, Connecticut, Delaware, Mississippi, Montana, New Hampshire, Vermont, and West Virginia), the proportion of women in need served by subsidized providers in 1994 exceeded 60%. In contrast, in six states (Hawaii, Illinois, Louisiana, Nebraska, Ohio and Utah), the proportion of women in need served by subsidized providers was less than 35%. Although these figures may reflect differences in service availability in various areas of the country, interpretations of these data for individual states must take into account other potential sources of care for low-income women that may not be included in the universe of subsidized family planning clinics.
A comparison of the numbers of women served at Title X-funded sites with the numbers of women in need of subsidized contraceptive care shows that only 28% of all women potentially eligible for subsidized care at a Title X-funded clinic in 1994 were actually served by these clinics. This proportion varies from a low of 23% in the midwestern states (Region V) to a high of 36% in the middle Atlantic states (Region III). At the state level, the variation in the proportion of women in need served at Title X-funded sites is even wider, and the states with relatively high proportions are not necessarily the same as those with high proportions of women served at all subsidized clinics. For example, in six states (Arizona, Louisiana, Minnesota, Oregon, Texas, and Utah), the proportion of women in need served at Title X-funded sites was 20% or lower, while in six other states (Arkansas, Kentucky, Maine, Montana, New Hampshire and West Virginia), the proportion was 48% or higher.
Overall, an estimated 39% of all women younger than 20 who were at risk of an unintended pregnancy (i.e., sexually active, fecund and not pregnant or trying to become pregnant) were served by subsidized family planning providers in 1994; 25% were served at sites funded through Title X. Again, these proportions vary considerably according to region and among states, with many of the same service patterns noted for all family planning clients.
An extensive network of publicly funded family planning clinic providers continues to serve the contraceptive needs of millions of women in the United States, many of whom would otherwise lack accessible and affordable contraceptive care. These clinic providers are located in every state and in 85% of all U.S. counties. Over time, this system has been remarkably stable, continuing to provide contraceptive services throughout the nation despite changes in the availability of public funding.
These clinics are especially crucial to the provision of family planning services in counties with small populations of women in need. Women in these counties, which are often rural and sparsely populated, are more likely to be served by family planning clinics (as opposed to other types of providers) than are women in more populated metropolitan counties. Because fewer family planning service options are available to women in sparsely populated counties, such women are more likely to be affected by any changes in the funding or delivery of services.
A majority of family planning clinics receive some federal funding through Title X of the Public Health Service Act, and 4.2 million women were served in 1994 at funded clinics in nearly 75% of U.S. counties. In fact, from the point of view of many clinic providers, Title X is the most important federal source of funding for contraceptive services. Although the Medicaid program allocates more total federal dollars to contraceptive care than does Title X, an unknown portion of the Medicaid funding goes to private physicians or managed care organizations that serve Medicaid recipients and is not available to clinic providers.
In addition, the Title X program provides basic service standards and requires that women with incomes below 100% of the federal poverty threshold be served for free, and that women with incomes between 100% and 250% of poverty be charged fees based on a sliding scale. These provisions allow all Title X-funded clinics to provide services at reduced fees to the many poor and low-income women who do not qualify for Medicaid. Although different providers, different regions and states, and counties of differing size vary in their level of dependence on Title X funding, clinics that do receive Title X funding serve, on average, more contraceptive clients than do clinics without Title X funding.
Thus, although the network of subsidized family planning providers receives considerable funding from the federal Title X and Medicaid programs, the family planning program reflects local needs and priorities. In fact, although we refer to these providers as a network, it is not one uniform system, but represents adaptation to the unique health care delivery systems and needs of different states and localities across the country.
A large number and wide variety of organizations are involved in the provision of family planning services, including health departments, hospitals, community and migrant health centers, independent agencies and Planned Parenthood affiliates. However, the relative importance of each provider type varies from region to region and locality to locality, with some areas heavily dependent on, for example, health department service providers, while other areas depend on another provider type or a mix of providers.
Different provider types also operate different numbers of clinic sites and serve varying numbers of contraceptive clients. For example, community and migrant health center sites serve, on average, fewer than 500 contraceptive clients per year, while Planned Parenthood clinics serve over 2,000 per year. We also know that agencies operated by different provider types tend to vary in the kinds of services offered, ranging from the provision of contraceptive care only to the provision of full primary care services.23
Finally, this diverse network of family planning clinics serves many women—6.6 million in 1994, representing, on average, 44% of all women in need of subsidized contraceptive services. In some states, family planning clinics served more than 75% of women in need, whereas in other states, they served fewer than 30% of such women. Moreover, nearly two million teenage women were served by family planning clinics, representing an average of nearly 40% of all teenagers estimated to be sexually active and in need of contraceptive services.
Continued access to quality contraceptive care is critical for the prevention of unintended pregnancies. Many women have few alternatives for obtaining the accessible and affordable contraceptive services that this network of clinics provides.
In "Family Planning Clinic Services in the United States, 1994" [28:92-100], by Jennifer J. Frost, a statement on p. 100 indicates that in some states family planning clinics serve more than 75% of women in need of contraceptive services. In fact, in no state do clinics serve more than 67% of such women.
* The definition of a family planning clinic provided to all respondents in this study is "a site where contraceptive counseling, education and services are provided. This includes sites providing comprehensive medical contraceptive services, i.e., sites where women can receive a medical examination related to the provision of a method for postponing or preventing conception performed by a physician, nurse-midwife, registered nurse or other authorized personnel. This definition also includes sites that provide counseling and education and dispense nonmedical methods of contraception without performing a medical examination, as long as an individual chart is created for at least some contraceptive clients."
** Agencies are classified as community or migrant health centers only if they are listed as receiving funds under section 329 or 330 of the Public Health Service Act. Other community agencies, including those receiving Bureau of Primary Health Care funding as Federally Qualified Health Center Look-Alikes, are classified here as independent agencies.
A contraceptive client was defined as "a woman who had made one initial or at least one return visit for contraceptive services during the 12-month reporting period. This includes all clients who have received a medical examination related to the provision of a method for postponing or preventing conception. In addition, this includes all active contraceptive clients for whom a chart is maintained, including those who made supply revisits during the 12-month period, but did not have a medical examination; clients who received counseling and method prescription and deferred the initial medical examination (i.e., new oral contraceptive clients) and women who chose the rhythm method or natural family planning. This definition DOES NOT include clients who received only abortion services, only pregnancy tests or only infertility services, or clients who received only counseling and were then referred to another provider for method prescription or provision."
For these estimates, women at risk of unintended pregnancy were defined as women who are sexually active, fecund and neither pregnant nor trying to become pregnant during the year; women relying on contraceptive sterilization of themselves or their partners are not included. Women who are in need of subsidized contraceptive services include all women at risk who are younger than 20, plus all women at risk aged 20-44 whose total family income was less than 250% of the federal poverty level ($31,685 for a family of four). This is the same level of poverty used to determine who is eligible to receive subsidized care at Title X-funded clinics. At these clinics, all women whose income is less than 100% of the federal poverty level are eligible to receive free services, while women with incomes between 100% and 250% of the poverty level are eligible to receive subsidized services based on a sliding fee scale.
1. W.D. Mosher, "Use of Family Planning Services in the United States: 1982 and 1988," Advance Data from Vital and Health Statistics, No. 184, 1990, Table 3, p. 3.
2. J. Silverman, A. Torres and J.D. Forrest, "Barriers to Contraceptive Services," Family Planning Perspectives, 19:94-102, 1987; and M. Chamie et al., "Factors Affecting Adolescents' Use of Family Planning Clinics," Family Planning Perspectives, 14:126-139, 1982.
3. The Alan Guttmacher Institute (AGI), Uneven and Unequal: Insurance Coverage and Reproductive Health Services, New York, 1995.
4. S.K. Henshaw and A. Torres, "Family Planning Agencies: Services, Policies and Funding," Family Planning Perspectives, 26:52-59 & 82, 1994; and D. Landry and J.D. Forrest, "Private Physicians' Provision of Contraceptive Services," unpublished manuscript, 1996.
5. M. Chamie et al., 1982, op. cit. (see reference 2).
6. A. Torres and J.D. Forrest, "Family Planning Clinic Services in the United States, 1983," Family Planning Perspectives, 17:30-35, 1985; ——, "Family Planning Services in U.S. Counties, 1983," Family Planning Perspectives, 19:54-58, 1987; and AGI, Organized Family Planning Services in the United States, 1981-1983, New York, 1984.
7. S.K. Henshaw and A. Torres, 1994, op. cit. (see reference 4).
8. D. Daley and R.B. Gold, "Public Funding for Contraceptive, Sterilization and Abortion Services, Fiscal Year 1992," Family Planning Perspectives, 25:244-251, 1993.
9. L. Kaeser, Title X at Twenty-five, AGI, New York, 1996.
10. D. Daley and R.B. Gold, 1993, op. cit. (see reference 8).
11. S. Henshaw and A. Torres, 1994, op. cit. (see reference 4).
12. D. Daley and R.B. Gold, 1993, op. cit. (see reference 8).
13. S. Henshaw and A. Torres, 1994, op. cit. (see reference 4).
14. U.S. Department of Health and Human Services, Family Planning Grantees, Delegates, and Clinics, 1994/1995 Directory, Bethesda, Md., 1994.
15. ——, Bureau of Primary Health Care: Primary Care Programs Directory, Bethesda, Md., 1994.
16. American Hospital Association, The 1994 AHA Guide, Chicago, Ill., 1994.
17. A. Torres and J.D. Forrest, 1985, op. cit. (see reference 6).
19. J.C. Smith, B. Franchino and J.F. Henneberry, "Surveillance of Family Planning Services at Title X Clinics and Characteristics of Women Receiving These Services, 1991," Morbidity and Mortality Weekly Report, Vol. 44, No. SS-2, pp. 1-21, 1995.
20. S.K. Henshaw and J.D. Forrest, Women at Risk of Unintended Pregnancy, 1990 Estimates, AGI, New York, 1993.
21. A. Torres and J.D. Forrest, 1987, op. cit. (see reference 6).
22. J.C. Smith, B. Franchino and J.F. Henneberry, 1995, op. cit. (see reference 19).
23. S.K. Henshaw and A. Torres, 1994, op. cit. (see reference 4).
Jennifer J. Frost is senior research associate at The Alan Guttmacher Institute, New York. The study on which this article is based was supported by the Office of Population Affairs, U.S. Department of Health and Human Services, under grant no. FPR000057.