Title X Improved Access To Most Effective And Moderately Effective Contraception In US Safety-Net Clinics, 2016–18

Nearly half (45 percent) of the more than six million annual pregnancies in the US are unintended;¹ reduction of unintended pregnancy is a national public health priority for both individual and community health.^2,3 Unintended pregnancy is associated with negative health and economic consequences,⁴ including delays in initiating prenatal care, reduced likelihood of breast-feeding, increased risks for maternal depression and intimate partner violence during pregnancy,^4,5 and lower maternal educational and economic achievement.^6,7 During the past two decades, disparities in who experiences unintended pregnancy have been widening, with unintended pregnancy becoming more concentrated among adolescents, women who are members of racial and ethnic minority groups, and women living in poverty.¹ Access to effective contraception is key to promoting reproductive autonomy by ensuring that individuals can realize their decisions about if and when to become pregnant.⁸

Community health centers, which include federally qualified health centers, rural health centers, and county health departments, are a crucial source of health care for low-income reproductive-age women.⁹ Community health centers meet the needs of their communities by providing care regardless of insurance or documentation status or ability to pay. As part of the obligations under Section 330 of the Public Health Service Act,¹⁰ federally qualified health centers must provide or arrange for access to voluntary family planning and reproductive health services. However, individual federally qualified health centers vary considerably in the scope and quality of family planning services they deliver,^11,12 and barriers persist to delivering contraceptive services, especially the most effective methods, known as long-acting reversible contraception (LARC): intrauterine devices and implants. These barriers include difficulties stocking devices on site, which makes provision of same-day LARC provision challenging;^13–16 the cost of contraceptive care, which is especially challenging when serving low-income and uninsured populations;^13,17,18 and lack of staff trained in LARC insertion and removal.^13–19

Some community health centers participate in the federal Title X family planning program, which provides supplemental funding for clinics to provide contraceptive services and supplies, sexually transmitted infection testing and treatment, and related sexual and reproductive health care.²⁰ The Title X program is a key payer for contraceptive services for low-income people.²¹ In contrast to Section 330 funding, Title X funding requires that clinics both provide on-site access to a broad range of contraceptive methods approved by the Food and Drug Administration (FDA)²² and adhere to national family planning quality guidelines.²³ Title X provides targeted funding, including site-level incentives to stock long-acting reversible contraception devices by covering up-front costs, which facilitates same-day provision,¹³ and training for staff to ensure appropriate staffing to provide a wide range of methods. Health centers that participate in Title X are therefore likely to provide more robust contraceptive services compared with centers not funded by Title X, as previous literature has found.^12,24

In 2019 the Trump-Pence administration weakened the Title X program by implementing non-evidence-based guidelines, including the prohibition of abortion referrals, removal of the requirement to provide a full range of FDA-approved contraceptive methods, and removal of confidentiality provisions for adolescents.²⁵ Many grantees and clinic sites left the Title X program altogether instead of complying with these changes, and the number of clients served by Title X dropped by 60 percent, going from 3.9 million in 2018 to 1.5 million in 2020.^26,27 The Biden-Harris administration reversed the Trump-Pence administration’s changes in October 2021.²⁸ Researchers and policy makers need comprehensive information about the role of Title X in the US safety net before the 2019 rule changes, because studies about the impact of weakening Title X in 2019 require a baseline for comparison. This study fills that gap.

The purpose of this study was to describe the provision of contraception in community health center clinics by Title X status and patient age in 2016–18, before the 2019 implementation of rule changes that weakened the Title X program.^25,29 Using patient-level electronic health record (EHR) data from 384 community health center clinics across the US, we assessed provision of the most effective (LARC) and moderately effective (oral pill, patch, contraceptive injection, and vaginal ring) contraceptive methods, using the Department of Health and Human Services Office of Population Affairs quality metric.³⁰ We hypothesized that Title X community health center clinics were more likely to provide the most effective methods of contraception than were non–Title X community health center clinics, especially for adolescents (ages 15–19).

Study Data And Methods

We used individual-level EHR data to conduct a retrospective cohort study to examine clinic-quarter rates of contraception provision by community health center clinics’ Title X funding status, adjusted for state, clinic, and individual patient characteristics.

Data

We used the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) clinical research network, a member of PCORnet.³¹ A total of 182 independent health systems in thirty-one states contribute data to ADVANCE.³² For this study, community health center clinics (that is, brick-and-mortar care locations) were selected when they met certain care type characteristics and patient volume criteria, described below. We used patient data from 384 community health center clinics in twenty states that were live on the EHR system by September 1, 2015 (four months before study start), and through the study end of December 31, 2018. We excluded clinics that did not provide primary care services (for example, dental clinics) or that provided fewer than fifty visits to women of reproductive age (15–49) per year (see the online appendix for details).³³

Within included clinics, we identified people who were documented as female in the EHR who were at risk for pregnancy, between the ages of fifteen and forty-nine, with at least one ambulatory encounter between January 1, 2016, and December 31, 2018. We were unable to comprehensively assess gender identity, so we use the term “women” throughout the analysis to refer to these patients. We used the Office of Population Affairs metric specifications to identify women at risk for pregnancy.³⁰ This metric is intended for use with claims or EHR data and does not incorporate pregnancy intention. Patients were determined to be at risk for pregnancy in the absence of any EHR evidence of sterilization, infecundity, or current pregnancy among structured EHR fields, consistent with previous literature and national metrics^30,34,35 (see the appendix for details).³³ We determined each woman’s eligibility for inclusion in the denominator each quarter.

Our outcomes were woman-level rates of the provision of the most effective (LARC) or moderately effective (short-acting hormonal methods)³⁶ contraception, following Office of Population Affairs quality metric specifications.³⁵ We extracted contraception information from several structured EHR fields, including prescription orders as identified by medication code and name searches and by records of medical procedures using Current Procedural Terminology, Healthcare Common Procedure Coding System, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), procedure codes, as well as ICD-10 diagnosis codes (see the appendix).³³

After identifying contraception provision by woman-quarter level, we aggregated data to the clinic-quarter level. We summed the incidence of provision of the most effective and moderately effective methods at the clinic-quarter level and then divided that sum by the total number of patients at risk for pregnancy in that clinic-quarter. This resulted in the unadjusted proportion of all patients at risk for pregnancy (denominator) who received the most effective or moderately effective contraception (numerator) per clinic-quarter.

Our main independent variable, clinics’ Title X funding status, was obtained by cross-referencing ADVANCE community health center and clinic locations with a list of Title X–funded clinics that we obtained from the Office of Population Affairs through a Freedom of Information Act records request.

We included patient covariates extracted from EHR records and aggregated to the clinic level overall. We classified women as adolescents (ages 15–19), young adults (ages 20–24), or adults (ages 25–49). We included proxy measures of systemic disparities affecting health care access:³⁷ clinic-level patient mix by race and ethnicity and by poverty level. Ethnicity was captured from patients’ self-reported Hispanic ethnicity or Spanish language preference. We refer to these women as “Latinx.” Non-Hispanic Black and White race were ascertained from patients’ EHR-recorded race and ethnicity. The clinic proportion of low-income patients (those with incomes from 0 to <138 percent of the federal poverty level) was based on patients’ first reported household income during the study period.

We included additional characteristics of the overall patient population at study clinics. We calculated the mean number of patients seen with ambulatory encounters during the study period. We calculated “patient mix” as the proportion of ambulatory encounters among women of reproductive age relative to ambulatory encounters among people of all ages and sexes and “payer mix” as the proportion of uninsured ambulatory encounters divided by the total number of ambulatory encounters per clinic. The proportion of women’s health specialist visits (“provider mix”) was the total count of ambulatory encounters among women of reproductive age at the clinic with a women’s health care specialist divided by the total number of ambulatory encounters among women of reproductive age. Data on medical specialty were captured from each provider’s National Provider Identifier data. We classified obstetricians, gynecologists, midwives, women’s health advanced practice clinicians, or maternal and fetal medicine providers as women’s health specialists.

Clinic locations were categorized as rural based on clinics’ site addresses, using 2010 rural-urban commuting area codes; locations classified as small town and smaller were categorized as rural.³⁸ We also included two state-level indicators: Medicaid expansion status (as of January 1, 2016)³⁹ and the presence of a state family planning program (Section 1115, state plan amendment, or family planning waiver).⁴⁰ We classified Wisconsin as a Medicaid expansion state, following previous literature,^41,42 given that the state expanded Medicaid to 100 percent of the federal poverty level in 2014, although it did so outside of the Affordable Care Act.

Analysis

We first calculated the mean clinic proportion of patients with demographic characteristics described above by clinic Title X status, in addition to clinic- and state-level characteristics of study clinics. Patient- and clinic-level covariates are presented as mean rates over all study clinics by Title X funding status. State-level covariates are presented as counts of study clinics by Title X funding status. Next, we calculated clinic-quarter rates of provision of the most effective and moderately effective contraception encounters.

We used a generalized estimating equation Poisson model to estimate rates of contraception provision, adjusted for the clinic, patient, and state characteristics described above, and we plotted the model-predicted population rates for each quarter by Title X status. The analytic unit for the models was the clinic-quarter. A total of 605,621 patients—49,909 patients with and 455,712 patients without contraceptive provision—were observed at 384 clinics over the course of the three years (twelve quarters) of the study. All clinics contributed data for each quarter. Using these patient-level data, aggregated to the clinic-quarter level, we used a total of 4,608 clinic-quarters of data in the models.

Models were performed for the overall sample and stratified by age group, as described above. To compare results in aggregate across the entire study period, we calculated adjusted squares means estimates for all quarters and compared averaged Title X estimates with those from clinics not funded by Title X. We used an autoregressive correlational structure and an empirical sandwich variance estimator to account for temporal correlation, and we included an offset of the log of the total number of women at risk for pregnancy in each clinic to account for differences in overall clinic size.

We conducted two sensitivity analyses. First, to account for clinics that did not have a reproductive health focus, we excluded fifty-five clinics with a large proportion of mental health encounters (above the seventy-fifth percentile) despite their not being classified as mental health clinics in the EHR metadata. Second, we excluded ninety-seven “lower-volume” clinics that were in the bottom quartile of visits for women of reproductive age. We did this to remove clinics not likely to provide contraceptive services. The results were robust to these changes, and we present our main analysis only. All analyses were conducted in SAS, version 7.15, and figures were prepared in R, version 3.6.2. This study was approved by the Western Institutional Review Board.

Limitations

This study had several limitations. First, our sample of community health centers might not be generalizable to all patients in community health centers, community health center clinics, or states. However, our data came from the largest national set of data from people obtaining care in safety-net settings, and the ADVANCE patient population is demographically and clinically similar to the overall community health center population.³¹ Second, our sample of Title X clinics might not represent the universe of Title X clinics. We compared our sample patient characteristics with data reported by the Title X program; our sample skewed younger and had a lower proportion of women who are Black and non-Hispanic than the population of the overall Title X program.²⁷ However, few studies are able to compare clinics with Title X funding to those without it across multiple states and with patient-level objective data, as we have done using this data set. Third, there may be unmeasured differences between Title X and non–Title X community health center clinics that our study did not capture. We controlled for patient, provider, and payer mix at the clinics in our sample. Fourth, we were not able to comprehensively identify gender identity among patients in our sample, and we did not have access to an organ inventory to assess risk for pregnancy. This may have resulted in misclassification of risk for pregnancy,⁴³ however small.

Study Results

Of 384 community health center clinics included in the analysis, 12 percent ($n=46$) were funded by Title X, and 88 percent ($n=338$) were not (exhibit 1). At the clinic level, Title X clinics saw a significantly larger proportion of women ages 15–49 at risk for pregnancy (4,272) than non–Title X clinics (3,228) did. Title X clinics served a significantly lower proportion of Black, non-Latinx patients (9.0 percent) compared with non–Title X clinics (16.6 percent). Title X clinics also saw a slightly larger proportion of adolescents (29.0 percent and 26.9 percent, respectively) and young adult women (13.9 percent and 11.1 percent, respectively). A larger but nonsignificant proportion of women served in Title X clinics had incomes below 138 percent of the federal poverty level (63.2 percent) compared with non–Title X clinics (59.8 percent). Title X clinics had a larger proportion of all encounters among women ages 15–49 (44.1 percent) compared with non–Title X clinics (34.6 percent). Provider and payer mix were similar by Title X clinic status. Nearly all (97.8 percent) Title X clinics were in states that expanded Medicaid; approximately two thirds of non–Title X clinics (66.6 percent) were in Medicaid expansion states.

During the three-year study period, adjusted clinic-quarter rates of the most effective and moderately effective contraceptive methods remained stable, with Title X clinics providing both the most effective and moderately effective methods at a higher rate than non–Title X clinics (exhibits 2 and 3, respectively). In the last quarter of the study, Title X–funded clinics provided the most effective methods of contraception to 2.2 percent of women at risk for pregnancy and moderately effective methods to 15.8 percent of at-risk women compared with 1.6 percent and 9.5 percent, respectively, among clinics not funded by Title X ($p=0.001$ most effective; $p<0.001$ moderately effective).

SOURCE Study-generated data. NOTES Data are from 384 community health center clinics in 20 states. Shaded areas indicate 95% confidence intervals. Model results were calculated using generalized estimating equation Poisson with indicators for each clinic-quarter, adjusting for clinic-level patient demographics and clinic- and state-level covariates.

SOURCE Study-generated data. NOTES Data are from 384 community health center clinics in 20 states. Shaded areas indicate 95% confidence intervals. Model results were calculated using generalized estimating equation Poisson with indicators for each clinic-quarter, adjusting for clinic-level patient demographics and clinic- and state-level covariates.

Title X clinics had the highest rates of most effective method provision among young adults and adolescents during the study period (see the appendix for details).³³ Averaged across all study quarters ($n=4,608$ clinic-quarters), Title X–funded clinics provided 52 percent more of the most effective contraceptives to women at risk for pregnancy than clinics not funded by Title X (adjusted relative rate = 1.52; $p=0.001$) (exhibit 4). Provision of the most effective contraception at Title X clinics was more pronounced among adolescents (58 percent higher) than among young adults (26 percent higher) and adults (46 percent higher) compared with non–Title X clinics.

Discussion

Using EHR data across a large sample US safety-net clinics, we show that community health center clinics that receive Title X funding consistently provide access to the most effective and moderately effective contraception at higher rates (52 percent more most effective and 49 percent moderately effective) than clinics that do not receive Title X funding. This finding was consistent during each quarter of the three-year study period and across all age groups. Our findings demonstrate that clinics in the Title X program provide better access to the most effective and moderately effective contraceptive methods. We found that Title X clinics were 58 percent more likely to provide the most effective contraception and 35 percent more likely to provide moderately effective contraception to adolescents compared with non–Title X clinics.

Our results support previous work, which has shown that Title X clinics provide access to effective contraception. However, evidence that compares Title X clinics with other safety-net providers has been limited to single states,^44–47 relied on site-level data,^47–49 or focused on the Medicaid expansion period.³⁴ Previous work has highlighted the important role of Title X in states that did not expand Medicaid in providing access to contraception^34,50 and in school-based health center clinics.⁵¹ We found a similar important role for Tile X in providing access to effective contraception across states and safety-net clinics.

Our results indicate that Title X community health center clinics are key access points for effective contraception for adolescents.

Our results also indicate that Title X community health center clinics are key access points for effective contraception for adolescents. Adolescents have been shown to choose and continue LARC methods when cost barriers are removed,^52,53 but provider bias and lack of provider training can pose barriers to adolescents’ access to LARC.^54,55 Young women and women who are members of racial and ethnic minority groups are more likely to report experiences of coercion or lack of autonomy; it is critical that all contraceptive counseling be centered in a reproductive justice framework that focuses on meeting the needs of the individual.^56,57 The Title X program ensures that its funded clinics receive specialized training in evidence-based reproductive health care, including specialty training in patient-centered counseling, that centers on the needs of the individual and avoids coercion.⁵⁸ Developmentally appropriate, patient-centered counseling and shared decision making can emphasize attention to the needs and preferences of adolescents^59,60 and ensure human rights.⁶¹ Adolescents were specifically targeted under the changes that the Trump-Pence administration made to the Title X program, as confidentiality provisions, which are known to be especially important to adolescents,^62,63 were removed, prioritizing parental involvement in care. We show that Title X clinics are key to supporting access to LARC for adolescents who seek care in community health centers; the Biden-Harris administration’s reversal of the Trump-era changes reinstates confidentiality provisions, allowing the Title X network to provide high-quality contraceptive care to adolescents.

Policy Implications

Strengthening Title X should continue to be a national health policy priority.

Our results provide key evidence about contraceptive service delivery at community health centers and the important role of Title X funding in the community health center network. Our results are from 2016–18, the period preceding important changes made to the Title X program by the Trump-Pence administration. These changes included prohibition of abortion referrals, complete financial and physical separation of abortion services from other services, removal of the requirement to provide a full range of FDA-approved contraceptive methods, and removal of confidentiality provisions for adolescents.²⁵ These changes significantly decreased the capacity of the Title X program, as one in five grantees left the program.^27,64 The impacts of these changes are expected to be most harmful among adolescents and among women who are uninsured or underinsured or who rely on Title X funding to obtain contraception.^20,65,66 In its reversal of the Trump-Pence administration’s changes,^25,67 the Biden-Harris administration invited former grantees to reapply for Title X funding.²⁶ Future work focusing on the impact of this disruption in the Title X network, such as the impact that the 2019 rule changes had on national rates of adolescent pregnancy, requires a baseline for comparison. Our results clearly show that Title X expands access to effective contraception in the US safety net, and strengthening Title X should continue to be a national health policy priority.

Conclusion

In sum, we found that in a large network of safety-net clinics, community health center clinics that receive funding through the Title X family planning program provide both the most effective and moderately effective contraception at higher rates than clinics not funded by Title X. Their impacts are especially notable for adolescents, underscoring the role of Title X in providing access to contraception for the adolescent population across the safety net. Recent action by the Biden-Harris administration to reverse the Trump-era rule changes⁶⁸ is a promising step toward protecting and enhancing access to effective contraception for low-income women nationally.

ACKNOWLEDGMENTS

This study was funded by the Office of Population Affairs (OPA) (1 FPRPA006071-01-00; Blair Darney, principal investigator). Additional funding was provided by the Agency for Healthcare Research and Quality (AHRQ) (1R01HS025155-01; Erika Cottrell, principal investigator). This work was conducted with the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) Clinical Research Network (CRN). ADVANCE is a CRN in PCORnet, the National Patient Centered Outcomes Research Network. ADVANCE is led by OCHIN in partnership with Health Choice Network, Fenway Health, and Oregon Health & Science University. ADVANCE’s participation in PCORnet is funded through the Patient-Centered Outcomes Research Institute (PCORI), Contract No. RI-OCHIN-01-MC. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Preliminary findings were presented at the 48th Annual Meeting of the North American Primary Care Research Group (virtual), November 20–24, 2020; Population Association of America, 2021 Annual Meeting (virtual), May 5–8, 2021; and Title X Grantee Conference (virtual), July 13–16, 2021. Darney’s institution receives research support from Merck/Organon. Darney also serves on the board of directors of the Society of Family Planning. Maria Rodriguez has served as a contraceptive trainer for Merck and the American Congress of Obstetricians and Gynecologists. She has served on an advisory board for Bayer and as a consultant for the World Health Organization. Her institution has received research funding from Arnold Ventures, the National Institutes of Health, Merck, and the Robert Wood Johnson Foundation on projects where she is the primary investigator. These potential conflicts of interest for Rodriguez have been reviewed and managed by Oregon Health & Science University.

NOTES

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