Contraceptive Methods Available to Patients of Office-Based Physicians and Title X Clinics --- United States, 2009--2010

Unintended pregnancies, which accounted for an estimated 49% of all pregnancies in the United States in 2001, more often are associated with adverse outcomes for both mother and child than are intended pregnancies (1). In 2008, an estimated 36 million U.S. women of reproductive age were in need of family planning services because they were sexually active, able to get pregnant, and not trying to get pregnant; this represented a 6% increase from year 2000 estimates (2). To assess the provision of various reversible contraceptive methods by U.S family planning providers, CDC mailed a survey on contraceptive provision to random samples of 2,000 office-based physicians and 2,000 federally funded Title X clinics. This report summarizes those results, which indicated that a greater proportion of Title X clinic providers than office-based physicians offered on-site availability of a number of methods, including injectable depot medroxyprogesterone acetate (DMPA) (96.6% versus 60.9%) and combined oral contraceptive pills (92.1% versus 48.8%). However, a greater proportion of office-based physicians than Title X clinic providers reported on-site availability of the levonorgestrel-releasing intrauterine device (LNG-IUD) (56.4% versus 46.6%). Less than maximal use of long-acting, reversible contraceptive methods (LARCs), including IUDs and contraceptive implants, might be a contributing factor to high unintended pregnancy rates in the United States (3). Improving contraceptive delivery by increasing on-site availability in physicians' offices and clinics of a range of contraceptive methods, including LARCs, might increase contraceptive use and reduce rates of unintended pregnancy.

From December 2009 to March 2010, CDC conducted a mailed survey on contraceptive provision to random samples of 2,000 office-based physicians and 2,000 federally funded Title X clinics. Office-based physicians were sampled from the American Medical Association (AMA) Physician Masterfile, which includes information on AMA member and nonmember physicians residing in the United States and select territories. Three primary specialties were included: obstetrics/gynecology, family medicine, and adolescent medicine. Title X clinics, which can represent a range of provider agencies (e.g., public health departments, Planned Parenthood affiliates, hospitals, and community health centers), were sampled randomly from a current directory of Title X clinics maintained by the U.S. Department of Health and Human Services' Office of Population Affairs. Office-based physicians and one provider from each Title X clinic were eligible to participate if they provided family planning services* to women of reproductive age at least twice per week.

The survey included questions on contraceptive method availability and determined whether specific reversible contraceptive methods were 1) directly available to clients on-site, 2) available by prescription (or recommendation, for condoms), 3) available by referral, or 4) not available. For providers reporting multiple categories of availability for a single method (e.g., on-site and by prescription), availability was classified according to the most accessible availability category (i.e., on-site, by prescription, or by referral to other providers, respectively). Surveys were pilot tested with physicians representing each targeted specialty, nurse practitioners, certified nurse midwives, and epidemiologists. Survey packets included a cover letter with signatures of support from key partner agencies and organizations. The initial survey mailing was followed by a reminder post card and a second survey mailing to nonresponders. Additional, systematic efforts to contact nonresponders were made by telephone.

Of the 2,000 office-based physicians sampled, 628 were excluded because they did not meet the eligibility criteria or could not be located. Of the 2,000 Title X clinics sampled, 334 were excluded because their providers did not meet the eligibility criteria, the clinic was closed, or it could not be located. After accounting for ineligibility, the response rate was 47.0% for office-based physicians and 78.5% for Title X clinic providers. The final sample included 635 office-based physicians and 1,368 Title X clinic providers.

A significantly higher proportion of Title X clinic providers than office-based physicians reported on-site availability of all methods (p<0.05), except the LNG-IUD, for which on-site availability was reported by 56.4% of office-based physicians and 46.6% of Title X clinic providers (Table). In contrast, a higher proportion of office-based physicians than Title X clinic providers reported prescribing or recommending each contraceptive method rather than having it available on-site, especially combined oral contraceptives (50.4% versus 6.9%), progestin-only oral contraceptives (70.9% versus 17.4%), DMPA (36.4% versus 2.6%), the contraceptive patch (60.5% versus 29.0%), and male condoms (60.8% versus 2.9%). The proportion of Title X clinic providers and office-based physicians who reported referring patients to other providers for contraceptive methods was low (≤8.0%), except for LARCs (including the copper IUD, 29.6% and 25.2%, respectively; LNG-IUD, 37.9% and 24.6%, respectively; and contraceptive implants, 44.5% and 40.0%, respectively. Few family planning providers indicated that specific contraceptive methods were unavailable to their patients; female condoms and implants most frequently were reported as unavailable by office-based physicians (17.8% and 8.0%, respectively) and Title X clinic providers (9.9% and 9.2%, respectively).

Reported by

SB Moskosky, Office of Family Planning, Office of Population Affairs; LB Zapata, PhD, MK Whiteman, PhD, SD Hillis, PhD, KM Curtis, PhD, PA Marchbanks, PhD, Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; CP Tyler, PhD, EIS Officer, CDC.

Editorial Note

Despite advances in contraceptive technology, the proportion of U.S. pregnancies that are unintended has remained relatively stable at approximately 50% (1). High unintended pregnancy rates in the United States are thought to result, in part, from lesser use of LARCs, which are highly effective (<1% typical use failure rates), compared with more commonly used methods, such as male condoms (15% typical use failure rate) and oral contraceptives (8% typical use failure rate) (3). LARCs are more effective at preventing unintended pregnancies during typical use than user-dependent methods (e.g., condoms and oral contraceptives) because they require only a single act of insertion for long-term use and eliminate the influence of adherence on effectiveness. Access to a range of contraceptive methods, including LARCs, might increase contraceptive use but might be impeded by cost, provider knowledge and training, or other factors (4).

Results of this national survey indicate variation in the availability of specific contraceptive methods by method type and by clinical setting, with a higher proportion of Title X clinic providers than office-based physicians offering a range of contraceptive methods on-site. Oral contraceptives, the most commonly used reversible contraceptive method among U.S. women (5), were available on-site from nearly all Title X clinic providers, whereas approximately half of office-based physicians had them available on-site and half had them available by prescription. Male condoms, which provide protection against both unintended pregnancy and sexually transmitted infections, were available on-site in nearly all Title X clinics but only in one quarter of physicians' offices. Availability of LARCs, which require insertion by a trained health-care provider, often depended on referral to other providers. Approximately one quarter of office-based physicians and nearly one third of Title X clinic providers referred clients to other providers for IUDs, and both often referred clients seeking implants to other providers, which could impede use of these contraceptive methods.

This is believed to be the only national survey to report on-site availability of specific contraceptive methods apart from availability though prescription or provider recommendation. Other studies on contraceptive method availability examined on-site availability in combination with prescription or provider recommendation (6,7), or examined on-site availability but combined all hormonal methods into one category (8). The findings are comparable to those of previous studies that found that contraceptive method availability either from on-site provision or through prescription or provider recommendation was highest for oral contraceptives and lower for the patch, IUD, and vaginal ring (6--8).

Differences in the availability of specific contraceptive methods might reflect variation in factors such as the reimbursable cost for each method (e.g., LARCs) (7), clinic or practice type and associated mandates (e.g., health department versus Planned Parenthood clinic) (7,9), federal and state policies (9), provider training in contraceptive implant or IUD insertion (8), health insurance coverage, and patient characteristics (8). For example, on-site availability for a range of contraceptive methods might be greater through Title X clinic providers than through office-based physicians because of 1) the federal Title X mandate to provide a broad range of contraceptive methods to all women, and 2) the larger proportion of patients seen at Title X clinics who are in need of contraceptive services (10). Additionally, social and demographic differences in patient population or a broad practice scope for office-based physicians could translate to fewer women seeking family planning services in these settings and might have led to lower on-site availability.

The findings in this report are subject to at least three limitations. First, although the 47.0% response rate for office-based physicians was similar to that of another physician provider survey (6), the rate was considerably lower than the response rate for Title X clinic providers (78.5%). Potential differences between respondents and nonrespondents in contraceptive method availability could not be determined. Second, the survey did not ascertain reasons for certain contraceptive methods being unavailable. Finally, although Title X providers might indicate that specific methods are available on-site, certain methods (e.g., LNG-IUD) are not available consistently to all clients because of high costs. Clinics or practices might opt to offer less expensive methods to some persons to have funds to serve a greater number of clients (7).

Descriptions of reversible contraceptive method availability among office-based physicians and Title X clinic providers can help guide practice, financing, and policy efforts aimed at improving contraceptive delivery. Reducing barriers to accessing a range of contraceptive methods, including LARCs, might reduce rates of unintended pregnancy in the United States.

References

1. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006;38:90--6.
2. Frost JJ, Henshaw SK, Sonfield A. Contraceptive needs and services: national and state data, 2008 update. New York, New York: Guttmacher Institute; 2010. Available at http://www.guttmacher.org/pubs/win/contraceptive-needs-2008.pdf. Accessed January 4, 2011.
3. American College of Obstetricians and Gynecologists Committee on Gynecologic Practice, Long-Acting Reversible Contraception Workgroup. Increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol 2009;114:1434--8.
4. Speidel JJ, Harper CC, Shields WC. The potential of long-acting reversible contraception to decrease unintended pregnancy. Contraception 2008;78:197--200.
5. Mosher WD, Jones J. Use of contraception in the United States: 1982--2008. Vital Health Stat 2010;23(29).
6. Landry DJ, Wei J, Frost JJ. Public and private providers' involvement in improving their patients' contraceptive use. Contraception 2008;78:42--51.
7. Lindberg LD, Frost JJ, Sten C, Dailard C. The provision and funding of contraceptive services at publicly funded family planning agencies: 1995--2003. Perspect Sex Reprod Health 2006;38:37--45.
8. Cope JR, Yano EM, Lee ML, Washington DL. Determinants of contraceptive availability at medical facilities in the Department of Veterans Affairs. J Gen Intern Med 2006;21(Suppl 3):S33--9.
9. Klerman LV, Johnson KA, Chang CH, Wright-Slaughter P, Goodman DC. Accessibility of family planning services: impact of structural and organizational factors. Matern Child Health J 2007;11:19--26.
10. Lindberg LD, Frost JJ, Sten C, Dailard C. Provision of contraceptive and related services by publicly funded family planning clinics, 2003. Perspect Sex Reprod Health 2006;38:139--47.