In April, the U.S. Office of Population Affairs (OPA) released updated programmatic requirements for the Title X national family planning program, the first update since 2001.1 Concurrently, and in conjunction with the Centers for Disease Control and Prevention, OPA also released evidence-informed clinical recommendations for family planning services.2 These guidelines are designed to set the standard for U.S. family planning services regardless of whether they are provided in the context of Title X. Publishing clinical guidelines separately from programmatic requirements is a new tactic for the agencies, intended to promote the guidelines’ use by public and private providers nationwide and to ease the process of updating each component.
As in the past, the Title X program requirements lay out the core tenets of Title X: providing accessible, affordable, confidential and high-quality family planning services on a fully voluntary basis. The updated requirements direct grantees to provide a broad range of contraceptive methods to all women, men and adolescents who are seeking such care. Clients must be provided with services regardless of their ability to pay; the lowest income clients must be provided care without charge, and higher income clients must pay according to a sliding fee scale. In addition, the requirements make clear that care for Title X clients must be confidential, and providers must establish protections to ensure that clients’ information is not disclosed without their consent.
The clinical guidelines define the core services of family planning care, and what a family planning visit should look like. Based on reviews of available scientific evidence and expert recommendations, the guidelines walk through six specific components of family planning (see chart). The guidelines additionally recommend that providers use family planning visits to offer several related preventive health services, such as screening for breast and cervical cancer; they also recommend offering other general preventive care, either on-site or by referral.
One area of emphasis in the guidelines is the type of information that should be provided to clients in the course of contraceptive counseling. This counseling should stress information about contraceptive method effectiveness, which is critical for clients to make informed decisions about which method is best for them. Providers are also encouraged to incorporate information about proper use, ancillary benefits, side effects and STI protection or lack thereof.
Not every health care provider offers preconception care and basic infertility services as routine parts of family planning, but the guidelines make clear that they should. Preconception care is defined to include a range of preventive services—such as screening for intimate partner violence, for alcohol, drug and tobacco use, and for hypertension and diabetes—meant to improve the health of the client and reduce adverse pregnancy outcomes. The guidelines recommend that basic infertility care include screening for causes of infertility among both female and male clients reporting difficulty conceiving, as well as appropriate referrals for further diagnosis and treatment.
As adult women are not the only family planning clients, the guidelines detail how the core components of a family planning visit may be tailored to address the needs of male and adolescent clients. The guidelines make clear that men’s services are not limited to condoms and vasectomy, but also include medical histories, infertility care, preconception care and STI services. Contraceptive counseling for adolescents should emphasize abstinence as an effective method to prevent pregnancy and STI acquisition but also should include comprehensive information on other options, including long-acting reversible contraceptives. Additionally, the guidelines recommend that providers encourage adolescents to talk with their parents about their sexual and reproductive choices.
Finally, the guidelines recommend that family planning providers establish quality improvement plans, and help providers to identify appropriate quality measures, collect the information needed and use those findings to effect change. Sites are encouraged to assess issues such as provider performance, method availability, cultural competency and client satisfaction via such tools as medical record reviews and exit interviews with clients. The ultimate goal of these quality improvement efforts is to ensure the best possible service provision, which will thereby reduce negative outcomes such as unintended pregnancy. —Andrea Rowan
1. Office of Population Affairs, Program Requirements for Title X Funded Family Planning Projects, Rockville, MD: Department of Health and Human Services, 2014, <http://www.hhs.gov/opa/pdfs/ogc-cleared-final-april.pdf>, accessed May 20, 2014.
2. Gavin L et al., Providing quality family planning services: recommendations of CDC and the U.S. Office of Population Affairs, MMWR, 2014, 63(RR-4): 1–54, <http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf>, accessed May 20, 2014.