Specialized Family Planning Clinics in the United States: Why Women Choose Them and Their Role in Meeting Women's Health Care Needs

We surveyed 2,094 women receiving services from 22 family planning clinics in 13 states between October 2011 and January 2012. The sampled clinics were purposively selected from among the respondents to a previous nationally representative survey of family planning clinics in the United States, as well as by contacting state or regional Title X program administrators to request their advice and help in identifying sites that met our specific two-factor criteria: 1) Being a reproductive health–focused family planning clinic and 2) being located in a community with available comprehensive primary care providers. Potentially eligible clinics were identified from the prior survey based on their response to two questions. The first asked administrators to identify the clinic's ‘primary service focus,’ with the following response codes: Reproductive health, primary health care, or other. The second question asked administrators whether there were primary care clinics available in their community. During sample selection, we identified several sites in a state based on their responses to these questions and then contacted a Title X administrator in each state to help us to choose the sites that best met our criteria, or to identify alternative sites. Two thirds of the final sample of clinics had been part of the prior survey sample and one third of the sample was identified from administrator recommendations. The participating facilities represent a range of provider types (e.g., Planned Parenthood clinics, health department clinics, hospital clinics, and independent family planning centers) and geographic regions, and were located in Alaska, California, Colorado, Iowa, Indiana, Kentucky, Louisiana, Massachusetts, Montana, Oregon, Pennsylvania, Texas, and Utah.

During fieldwork, we contacted the clinic or agency administrator at each sampled site to request their participation in the study. In some cases, several layers of review were required before participation was granted. Survey materials and instructions were provided to clinic managers at each participating site, and clinic staff were instructed to distribute the questionnaire to every eligible patient during the fielding period. All female clients, except those coming in for pregnancy-related services, were eligible to participate. Women completed the questionnaire on-site and returned it to clinic staff in a sealed envelope to ensure anonymity and confidentiality. The fielding period lasted 1 to 4 weeks at each clinic depending on patient volume (clinics with low patient volume were in the field for longer periods). Regular follow-up was conducted with clinic managers to answer questions and guide them through the fieldwork period; a $100 gift card was offered to each clinic as an incentive. One respondent at each site was also selected to win a $100 gift card incentive. Clinic staff distributed raffle entry forms to each respondent and one winner was randomly selected from each clinic at the end of the fielding period. At the end of fieldwork, each clinic reported the total number of eligible clients seen during the fielding period. Clinics that failed to achieve a minimum 50% response rate were excluded from analysis (only one clinic fell into this category).The four-page survey instrument consisted of mostly closed-ended questions and was available in both English and Spanish. Surveys were pretested with English-and Spanish-speaking family planning clinic patients, and changes were made after pretesting to enhance comprehensibility and respond to patient concerns. The questionnaire asked women about the reason for their visit, the desired features that led them to visit that specific facility, what medical services they had received in the prior year, and where they received those services. Demographic characteristics and information about health insurance coverage were also collected. The survey instrument and protocols were approved by our organization's institutional review board.

Of the 27 clinics identified for this study, three refused to participate, one was found to be ineligible, and one failed to reach a 50% response rate among clients. The remaining 22 clinics reported a total of 3,105 eligible female clients seen during the survey period and usable data were collected from 2,094 of these clients, for a response rate of 67%.

Analyses were performed using SPSS Statistics version 18 (SPSS, Inc., Chicago, IL), using the complex samples procedures. Results are based on unweighted data, and the clustered nature of the sample has been accounted for in analysis and significance testing. Comparisons among subgroups of women have been tested for significance using independent group t-tests, and significance is reported for comparisons at p < .05.

A majority of female respondents seeking services at specialized family planning clinics were under age 25–22% were teenagers and 34% were aged 20 to 24 (Table 1). Most clients had no children (58%) and most were neither married nor living with a partner (63%). Sixty-one percent of client respondents had an income below 100% of the federal poverty level, and an additional one quarter of clients had incomes between 100% and 200% of poverty. One in three respondents were on Medicaid or had some other form of public health insurance; 22% had private health insurance and 42% were uninsured. Half of respondents were non-Hispanic white (51%) and about one fifth were either non-Hispanic Black (21%) or Hispanic (23%). About 1 in 10 respondents spoke Spanish at home and a similar percentage was foreign born. Only one in five respondents indicated that this was their first visit to this clinic.

We compared the distribution of our respondents to the distribution of clients receiving care from Title X–funded clinics by key characteristics, such as age and race/ethnicity, and found them to be very similar, especially by age (Table 1). Some small variations between our sample and all Title X users can be seen in the poverty status and race/ethnicity distributions; however, the questions used to collect these data also vary between the two efforts and some variation may reflect different data collection methodologies.

Half of respondents (48%) said that their primary reason for visiting the clinic at the time of the survey was for contraception—either to receive a new method, to continue using a method or to talk about an issue they were having with their method (Table 2). One in four respondents (27%) was at the clinic for an annual gynecological examination (which may have included receipt of a contraceptive method). Ten percent of respondents were primarily at the clinic for a pregnancy test, 8% for STI services, and 7% for some other type of service. Teens were more likely than older women to visit the clinic for contraception and less likely to be there for an annual gynecological examination.

In the prior year, nearly two thirds (64%) of respondents had received an annual gynecological examination (either at the same clinic or at some other provider), 59% had received a general health examination, 47% had made a visit for an STI test or treatment, and 42% made a visit to a medical provider because they were sick. Teens and women without children were less likely to have made a visit for an annual gynecological examination compared with older women or women with children. Uninsured women were less likely to have received either a general health examination or a sick visit compared with women with public or private insurance.

We combined the results from these four questions about care received in the prior year, including information about where that care was obtained, to determine the percentage of respondents who had received no medical care prior to the current visit and the percentage whose only medical care had been obtained from the specialized family planning clinic they were visiting at the time of the survey.

Overall, in the past year, one in eight (12%) respondents made no prior visit for medical care, and 29% had only received care at the specialized family planning clinic. For these 41% of respondents, the specialized family planning clinic was their only source for medical care during the year. The majority of respondents (59%) had made at least one other visit for medical care in the prior year to a different provider, but when it came to making a visit for contraceptive or reproductive health care, they chose to visit a specialized family planning provider. Teens were less likely than older women to have only received prior care from the specialized family planning clinic. Uninsured women were more likely than privately insured women to have received no prior medical care or to have received all their care at the clinic—resulting in half of all uninsured women relying on the specialized family planning clinic as their only source of medical care. In contrast, only one in four (27%) women with private health insurance was relying solely on the specialized clinic for medical care.

Overall, 4 in 10 (42%) respondents had neither public nor private health insurance, 35% reported having Medicaid or some other form of public insurance, and 22% had private insurance (Table 3). African-American women were more likely than non-Hispanic White women to have public insurance; women with children, women under 100% of poverty, African-American women, and Hispanic women were less likely to have private insurance, compared with comparison groups. Among women with either public or private health insurance, about two thirds (68%) planned to use their insurance to pay for the visit they were making at the time of the survey, whereas one third (32%) did not.

We asked applicable women why they were not planning to use their insurance to pay for their current visit. Some (29%) did not think their insurance covered the service they were receiving, 18% were worried that someone might find out about the visit, 13% did not think their insurance could be used at the clinic, and 6% reported some other reason for not using insurance, including that services or methods were more expensive using their insurance, that their deductible was too high, or that they had forgotten to bring their insurance card. Teenagers were significantly more likely than women in their 30s to avoid using their insurance because of confidentiality concerns (31% vs. 4%).

Respondents were asked to indicate how important each of 18 different possible reasons was to their decision to visit the specialized family planning clinic, instead of going somewhere else for their care. Table 4 presents the percentages of respondents reporting that each reason was “very important” to their clinic choice and also creates seven summary groups of reasons that were substantively related, presenting percentages of respondents who reported that any of the two or three reasons in that group was very important to their choice.

The four individual reasons reported as very important by at least 80% of respondents were: “The staff here treat me respectfully” (84%), “Services here are confidential” (82%), “I can get free or low-cost services here” (80%), and “The staff here know about women's health”(80%). For teens, “Services here are confidential” was the top individual reason (86%), and for uninsured women, “I can get free or low-cost services” was the top reason (90%).

When reasons were combined into summary groups, six of the seven groups were reported as very important by more than 8 in 10 respondents (83%–89%). Accessibility was ranked at the top, with 89% of respondents reporting that at least one of three access-related reasons (location, hours, or wait time) was very important to their clinic choice. A similarly high percentage of respondents (88%) reported that the way they were treated by clinic staff (respectfully, or that staff take time to talk to me) was very important to their decision to visit the clinic. Affordability (either free or low-cost services or ability to use Medicaid) was very important to 85% of respondents; the same percentage reported that the clinic's focus on women's health (staff knowledge about women's health or easy to talk to staff about sex and birth control) was very important. Contraceptive method availability (can get the method I want or can get supplies, not just a prescription) was very important to 84% of respondents, and confidentiality (services are confidential or I won't see people I know) was very important to 83% of respondents. Just over half (56%) of respondents reported that having been referred to the clinic (either by friends, family, or another doctor or clinic) was very important to their choice to visit this clinic. For two thirds of respondents, the fact that staff at the clinic can refer them to other providers was very important to their choice; half of respondents said that the availability of teen or young adult services was important; and 17% reported that the availability of childcare was important.

Overall, there was relatively little variation among respondents in terms of what they valued and why they chose to visit the specialized family planning clinic. Accessible, affordable, confidential care delivered by respectful staff who are knowledgeable about contraceptive and reproductive health was considered very important by the vast majority of respondents from all major demographic subgroups. There were a few unsurprising variations: 92% of uninsured respondents reported that affordability was very important compared with 73% of respondents with private insurance. Method availability and confidentiality were relatively more important for teenagers compared with women in their 30s (88% vs. 76% for method availability and 88% vs. 81% for confidentiality), as was the availability of teen or young adult services. Women with children were more likely than those without to report that the availability of childcare was important to their clinic choice. There was also little variation in women's reasons for coming to the clinic by whether the respondent had received care from other providers during the year, had only visited this clinic, or had received no prior health care (data not shown).