Family planning providers have an important role to play in the response to the public health challenge posed by Zika. In the United States, there are high rates of unintended pregnancy, especially in states most at risk for mosquito-borne transmission of the Zika virus. This paper describes efforts by eight of these states (Arizona, California, Florida, Georgia, Louisiana, Mississippi, South Carolina, and Texas) to build capacity for quality family planning care in the context of Zika.
Drawing on resources developed by the Office of Population Affairs, including a toolkit for family planning care in the context of Zika, agencies and stakeholders involved in the family planning delivery system in Southern states at risk for mosquito-borne transmission met over several months in the summer of 2016 to coordinate efforts to respond to the risk of Zika in their jurisdictions.
Through proactive communication and collaboration, states took steps to integrate Zika-related family planning care, including screening for Zika risk and providing appropriate, client-centered counseling. Challenges faced by the states included not having family planning included as a component of their state's Zika response effort, limited funding for family planning activities, and the need for robust communication networks between multiple state and federal agencies.
The efforts described in this paper can help other states to integrate family planning into their Zika response. This is relevant to all states; even when mosquito-borne transmission is not occurring or expected, all states experience travel-related and sexually transmitted Zika infections.
The Zika virus has rapidly emerged since 2015 as a major public health threat, given its devastating effect on fetal development and the expanding geographic range of mosquitoes carrying the virus (
Petersen et al., 2016). Although the virus has been circulating in Puerto Rico and countries in the Caribbean, Central America, and South America since 2015, the urgency of taking action to mitigate the impact of the virus in the United States has received increased attention since June 2016, when mosquito-borne transmission in the continental United States was first documented (
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New England Journal of Medicine. 2016; 374: 1552-1563
Likos et al., 2016).
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Local mosquito-borne transmission of Zika virus: Miami-Dade and Broward Counties, Florida, June-August 2016.
MMWR Morbidity and Mortality Weekly Report. 2016; 65: 1032-1038
Given Zika's impact on reproductive outcomes and the fact that it is transmitted sexually, family planning services are a critical part of the public health response. To date, however, there has been limited attention to the role of family planning in preventing negative health consequences in the United States beyond the use of condoms to prevent sexual transmission. The importance of family planning services and the needs of nonpregnant women and men of reproductive age, for example, were not included in the Zika Action Plan Summit convened in April 2016, to help state public health leaders develop action plans for their states.
Therefore, there is a need for increased attention to building capacity for family planning services as a component of the response to Zika. Southern states in the range of the Aedes mosquito, which is known to transmit Zika, have a particularly urgent need to focus on this area given the potential of more widespread infection in these regions (Figure 1). Importantly, several of the states known to have potential for mosquito-borne transmission are among the lowest ranked in the country with regard to reproductive health care, with high levels of uninsured women of reproductive age and high rates of unintended pregnancy (
Dreweke, 2016). However, incorporating family planning in the response to Zika is relevant to all parts of the United States, given the potential for travel-related cases as well as sexual transmission of the virus. As of November 30, 2016, 4,310 travel-associated cases of Zika had been reported, with cases occurring in all U.S. states except Alaska (Figure 2).
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Countering Zika globally and in the United States: Women’s right to self-determination must be central.
Guttmacher Policy Review. 2016; 19
The U.S. Office of Population Affairs (OPA)—the agency within the federal government that serves as the focal point on family planning, including providing public funding for family planning services through the Title X Program—is one of the Federal agencies that has been working to help states expand access to contraceptive and other family planning services in the context of Zika. The purpose of this paper is to describe work done by eight states at high risk of mosquito-borne Zika transmission, in partnership with OPA. This work has concentrated on increasing awareness of the role of family planning as a key component in the response to Zika and encouraging collaboration across state agencies that care for nonpregnant women and men of reproductive age. Although the initial focus was on states considered to be most at risk for mosquito-borne transmission, we hope that the efforts of these states will motivate all states to expand access to contraceptive and other family planning services, and integrate Zika-related care into those services.
Materials and Methods
In June 2016, OPA convened a 2-day meeting of representatives from seven states from the Southern part of the United States (California, Florida, Georgia, Louisiana, Mississippi, South Carolina, and Texas). State representatives included individuals from the agencies that receive funding from the Title X family planning program, state Medicaid agencies, Federally Qualified Health Centers, state public health departments, state Primary Care Associations, rural health centers, and state chapters of the American College of Obstetricians and Gynecologists (ACOG). The meeting, held in Arlington, Virginia, also included representatives from a number of Federal agencies within the U.S. Department of Health and Human Services, including the Centers for Disease Control and Prevention (CDC), Indian Health Service, Office of Minority Health, Center for Medicaid and CHIP Services, the Bureau of Primary Health Care, the Office of the Assistant Secretary for Preparedness and Response, and the Office of Health Reform. Other interested national stakeholders, including the ACOG, the National Family Planning and Reproductive Health Association, the Association of State and Territorial Health Officials, and the State Family Planning Administrators also attended.
We first presented attendees with an overview of the role of family planning in the response to Zika, including the importance of maintaining a patient-centered approach to family planning services that prioritizes patient autonomy, even in the context of an emergency response. OPA then introduced several training and technical assistance resources that had been developed to help states integrate Zika-related care into existing programs. This included a core set of competencies for quality family planning care in the context of Zika that OPA had developed in alignment with the evidence-based recommendations in the CDC/OPA's “Providing Quality Family Planning Services” (
Gavin et al., 2014), incorporating specific needs and activities related to Zika and its attendant risks (Table 1). Resources to enable states to achieve these competencies ranged from comprehensive training and technical assistance programs designed to augment all aspects of care, including counseling, provision of all contraceptive methods, including long-acting reversible contraceptives (LARCs), and financial strategies to ensure sustainability, to those targeting specific competencies, such as online training programs focused on contraceptive counseling. We also reviewed the availability of a “Zika toolkit” developed by OPA and designed to operationalize the CDC's guidance for taking care of nonpregnant women and men with respect to the risks associated with Zika (
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Centers for Disease Control and Prevention
Providing quality family planning services: Recommendations of CDC and the U.S. Office of Population Affairs.
Providing quality family planning services: Recommendations of CDC and the U.S. Office of Population Affairs.
MMWR Recommended Reports. 2014; 63: 1-54
Dehlendorf et al., 2016).
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Providing family planning care in the context of Zika: A toolkit for providers from the US Office of Population Affairs.
Contraception. 2016; 95: 1-4
Table 1Core Competencies for Contraceptive and Other Related Family Planning Services in the Context of Zika
|Counseling and education|
|Management and administrative staff|
Abbreviations: CDC, Centers for Disease Control and Prevention; IUD, intrauterine device; STD, sexually transmitted disease.
After this orientation, state teams were asked to reflect on the extent to which their current family planning services integrated considerations related to Zika, as well as the needs of their service delivery networks with respect to the broader list of competencies. Each state group then discussed state-specific plans for leveraging these resources to build capacity for quality, accessible family planning services, including access to a broad range of contraceptive methods, in the context of Zika. At multiple points, the entire group was reconvened to discuss progress and to share previous lessons learned and ongoing challenges in their states. At the end of the meeting, states reported their progress in developing plans for future work within individual agencies and in collaborative efforts.
Two months after this meeting, in August 2016, we convened a virtual meeting of the seven original states to continue the opportunity for ongoing collaboration and to leverage states’ opportunities to learn from each other. Arizona was unable to participate in the first meeting, but given that it was at high risk of mosquito-borne Zika transmission, it was also invited to participate in the second meeting. In this meeting, each state provided a report on progress made since the initial meeting, as well as new challenges, and shared resources and ideas in an interactive discussion.
Initial In-Person Meeting
At the initial meeting in June 2016, states universally reported that contraception was not a part of their states’ Zika response plans, and that there was little integration of Zika-related care in their family planning networks. Notably, there was no routine screening of nonpregnant clients for possible infection and education about the virus. To improve the ability to provide this care, as well as to augment family planning services more generally, they identified the need to consider changes at the levels of both the health system and the provider.
On the highest level, states felt that family planning as a response to Zika had not been highlighted in the response of the state government and public health messaging about Zika. States viewed this as a missed opportunity to both raise awareness among family planning providers and create demand for these services from patients. Discussion focused on opportunities related to engaging with state emergency response teams to highlight the importance of family planning in the Zika response and to pursue potential funding opportunities.
From the perspective of health systems, states emphasized the value of drawing on existing training and technical assistance resources to fill gaps in the ability to achieve the identified competencies. One highlighted need was addressing gaps in care related to the provision of same-day insertion of intrauterine contraceptive devices and transdermal contraceptive implants. Also highlighted was the opportunity to build on recent Medicaid initiatives designed to remove payment barriers to contraceptives. These policies include reimbursement for placement of long-acting reversible methods of contraception (LARC or intrauterine devices and transdermal implants) immediately postpartum, covering the actual cost of the LARC devices, taking steps to ensure onsite availability of these methods, and removing logistical barriers (such as prior authorization) that prevent same-day provision (
Center for Medicaid and CHIP Services, 2016,
Center for Medicaid and CHIP Services
State Medicaid payment approaches to improve access to long-acting reversible contraception.
State Medicaid payment approaches to improve access to long-acting reversible contraception.
CMCS Informational Bulletin, Baltimore2016
Centers for Disease Control and Prevention, 2016), The possibility of expanding and formalizing referral networks for provision of contraceptive services was also noted, for example, by referring clients in need of family planning to Title X-funded clinics or other dedicated family planning providers. States perceived the emerging awareness of the threat associated with the Zika virus as an opportunity to motivate providers and systems to engage with quality improvement. At the same time, state representatives emphasized the real impact of resource limitations on their ability to expand their training and technical assistance efforts.
Centers for Disease Control and Prevention (CDC)
The 6/18 Initiative: Prevent unintended pregnancy.
The 6/18 Initiative: Prevent unintended pregnancy.
On a service provider level, states highlighted the importance of screening all individuals of reproductive age for Zika exposure, because such screening would both inform and motivate the provision of family planning care that takes into consideration an individual's level of risk for contracting the virus. The dissemination and use of the OPA Zika toolkit, including the availability of client handouts and community outreach materials, was viewed as a core strategy to facilitate integration of Zika-related care into family planning and other settings that care for nonpregnant women and men of reproductive age.
Follow-Up Virtual Meeting
At this meeting in August of 2016, state participants reported increased integration of Zika awareness into family planning care since the initial meeting in June 2016. Family planning had been added to the state emergency response plans in several states, and more than one-half of the states reported that providers were now routinely screening nonpregnant clients of reproductive age for possible Zika exposure. States also reported their progress in expanding access to quality family planning care in the context of Zika and lessons learned in the process, starting with Florida due to its recent experience with local mosquito-borne transmission.
- Florida: Florida representatives reported that family planning was an integrated component of the response to the finding of mosquito-borne transmission in Miami–Dade County, with health departments in areas with this transmission distributing Zika prevention toolkits (including condoms and information about local family planning clinics) door to door. Clinics in this area were reported to be well-prepared to provide family planning in the context of Zika, although it was not clear that this was true for the broader network of family planning providers outside Miami–Dade County. Intensive work was being conducted around communication, including weekly email communication from the State Department of Health with clinicians using a preestablished communication chain and dissemination through partners, such as the local ACOG chapter. The OPA Zika toolkit had been useful in their efforts to communicate with and support health care providers, although client materials in both Spanish and Haitian in addition to English were desired to reach a broader audience. The state representatives highlighted the value of the use of an incident command center, which had been initiated since the documentation of mosquito-borne transmission, as a means of coordinating Zika-related efforts on an emergency basis. With respect to lessons learned, the value of advanced planning conducted before having mosquito-borne transmission, and the importance of having knowledge of communication channels for dissemination of information, was emphasized.
- California: The Title X grantee in California, Essential Access Health, partnered with the California Primary Care Association to disseminate the OPA Zika toolkit and other related information to California's Title X network of family planning providers and other primary care providers throughout the state. Additionally, Essential Access Health's Learning Exchange integrated Zika-related resources and materials into existing patient-centered counseling and LARC provision trainings. Attempts had been made to organize a statewide convening but, owing to logistical difficulties, efforts were suspended. The most notable lesson learned was that developing a coordinated response in a state the size of California with relevant partners can be challenging, but leveraging preexisting relationships helped to get closer to the goal.
- Georgia: State representatives reported that family planning has been increasingly integrated into public health and health care provider messaging, including through Medicaid and managed care plans. The OPA Zika toolkit was distributed widely through the Department of Public Health, Title X, and obstetrics/gynecology and primary care clinics. To support this integration, the Title X grantee in Georgia (Family Health Centers of Georgia) incorporated an assessment of service sites' readiness and capacity to provide Zika-related care during their technical assistance visits. The Georgia Department of Public Health also launched a Zika awareness public health campaign, which included family planning considerations. Most of these efforts were facilitated by weekly Zika response conference calls with statewide partners, led by the state commissioner of public health. Georgia representatives highlighted the value of this collaboration as a key lesson learned, while also reporting that challenges included an ongoing lack of funding for expanding training and technical assistance, particularly related to the integration of Zika into family planning care, as well as less perceived urgency owing to an absence of local mosquito-borne transmission.
- Louisiana: The OPA Zika toolkit had been a key resource for health systems and providers in this state, with family planning experts having conducted presentations and training for audiences incorporating material from the toolkit, including the state rural health association and the state primary care association. In addition, Medicaid released a bulletin to its providers regarding Zika that included information regarding condoms, but not other contraceptive methods (Louisiana Department of Health, 2016). This bulletin facilitated a conversation about the importance of highlighting the role of family planning more generally, which led to a second bulletin with more specific information, as well as consistent messaging used by all members of the Zika response team. There were also plans for further training at the local public health clinics and the state nurse practitioners' association. The public health clinics integrated screening questions related to Zika into the electronic health record to facilitate Zika-related care. Ongoing challenges included the desire to have access to a more standardized set of training materials to accompany the Zika toolkit to facilitate its use and the need to reinforce referral networks to ensure access to all methods, including LARC.Louisiana Department of Health
Prevention of unintended pregnancy and risks associated with Zika.Informational Bulletin, 2016
- Mississippi: Working through an incident command center, the OPA Zika toolkit had been approved for distribution and county health department staff were being trained in its use. A centralized Office of Communication is coordinating public messaging, and although messages in airports and other venues were not including contraception, the Department of Health website included links to OPA and other relevant resources. There had been continued attention to training around LARC, and clinics operating throughout the state providing reproductive health services have the ability to provide these methods.
- South Carolina: The South Carolina Department of Health and Environmental Control (the Title X grantee) has worked extensively to disseminate information about Zika and family planning to the public and their network of providers through in-person presentations, Twitter, Facebook, emails, public service announcements, and other means. This includes posting the OPA Zika toolkit on the DHEC website.1Particular attention has been paid to the needs of the Latino community, including disseminating information in Spanish and collaborating with organizations that serve this population. Special care is being taken to ensure that women are aware of and can access services; among other things, the Title X grantee added a staff member to help individuals seeking Zika testing obtain care through family planning, if desired. In addition, the Title X grantee has collaborated with other state agencies, including Medicaid, and nonprofit organizations to leverage existing efforts to expand postpartum LARC availability through the South Carolina Birth Outcomes Initiative. Lessons learned from this state include the need for Medicaid to offer hospitals and providers additional training on postpartum LARC use, as well as the essential nature of maintaining communication channels with other agencies and providers.For more information, see the following link (under additional resources): http://www.scdhec.gov/Health/FHPF/DiseaseResourcesforHealthcareProviders/ZikaVirusGuidelines/.1For more information, see the following link (under additional resources): http://www.scdhec.gov/Health/FHPF/DiseaseResourcesforHealthcareProviders/ZikaVirusGuidelines/.
- Texas: Extensive efforts have been made by the Title X grantee (the Women's Health and Family Planning Association of Texas) to disseminate information about Zika as well as the OPA Zika toolkit, including convening a Title X Zika working group meeting with representatives from 28 clinics located in higher risk areas, and conducting a training for all members of the Title X network. Ongoing outreach included a Zika webinar to disseminate lessons learned from the working group and the distribution of Zika information, including the importance of discussing contraceptive options, to non-Title X providers. This work has been facilitated by long-standing relationships between the Title X grantee and statewide health care partners, including Medicaid and the state Women's Health programs. The Title X grantee has also developed a Zika evaluation plan to monitor, evaluate, and respond to ongoing challenges experienced by Title X providers in integrating Zika into family planning care. Lessons learned included the challenges of integrating all the desired training and capacity building without additional funding, as well as the need to actively monitor and reinforce referral networks to facilitate Zika testing, and maintaining availability of the full range of methods to all women.
- Arizona: Because this was the first meeting that included Arizona, most activities projected were future oriented. The OPA Zika toolkit will be distributed in 7 of the state's 15 counties through local health officials by the Title X grantee (the Arizona Family Health Partnership). Additional outreach regarding the role of family planning and training in the Zika response had also been conducted through ACOG, the state primary care association, the WIC program, U.S. Immigration and Customs Enforcement, and other social programs. These efforts have built on ongoing collaborations regarding LARC availability, including issues related to Medicaid reimbursement and provider training. The grantee also purchased ArizonaZika.org as well as 270,000 condoms and designed/printed outreach material in English and Spanish. Lessons learned included the need for additional funding for Title X grantees to take the lead on initiatives to focus on family planning in the context of Zika.
After the August 2016 meeting, OPA developed additional resources that state representatives indicated would be helpful, including a “meeting in a box” that compiled items they would need to facilitate a state-based discussion about Zika and family planning. In addition, OPA developed a draft protocol for monitoring family planning efforts in response to Zika, including quantitative and qualitative data collection tools to track both training and outreach activities and the provision of Zika-related family planning care (Table 2 provides links to these and other resources related to Zika-related family planning care).
Table 2Training and Technical Assistance Resources to Build Capacity for Quality Family Planning Services in the Context of Zika
|Resource||Where to Find It|
Core competencies for family planning in the context of Zika
The “Zika Toolkit”: Providing Family Planning Care for Non-Pregnant Women and Men of Reproductive Age in the Context of Zika: A Toolkit for Healthcare Providers
Zika Community of Practice
Zika Monitoring and Evaluation Protocol
Meeting in a Box
Abbreviations: CDC, Centers for Disease Control and Prevention; OPA, U.S. Office of Population Affairs.
Expanding access to contraceptive and other family planning services, including counseling, in the context of Zika is challenging for many reasons, including the fact that family planning services are not commonly part of emergency response efforts and, therefore, there is not a previously defined action plan for including these services. Specific challenges noted by states included the difficulty of managing the evolving nature of knowledge and recommendations related to the Zika virus. This challenge further highlights the value of establishing robust communication networks, which can be facilitated by collaboration across stakeholders. Other challenges were not having family planning included as a component of their state's Zika response effort, a shortage of trained providers, and limited funding for family planning activities. Further, the content and delivery of family planning services in the United States are frequently viewed as controversial, which can complicate efforts to provide funding for and focus attention on this aspect of health care.
Several state agencies and organizations involved in family planning services have been successful in beginning to overcome these challenges, with the assistance of technical assistance and facilitated collaboration both within and across states. All eight states reported taking concrete steps to expand contraceptive access and to integrate Zika-related considerations into family planning care provided in their states. Other states can learn from the successes and the challenges faced by these states, to advance the goal of mitigating the impact of Zika, as well as to enable women, men, and couples to achieve their reproductive goals more generally.
Implications for Policy and/or Practice
Based on the experience of the states included in this effort, specific actions that state agencies and organizations can take to accomplish the goal of expanding access to quality contraceptive care in the context of Zika include the following.
- •Ensuring that family planning is included as a component of the state's Zika response effort. This is important for states that are most likely to experience local transmission, but is also relevant for all states given the presence of travel-related exposures.
- •Taking steps to ensure all clients of reproductive age are screened for potential Zika exposure at each visit, and then counseled about the potential risks and steps they can take to reduce those risks. This effort will include training clinical providers how to screen for and educate clients about Zika, helping clients to consider how potential for Zika infection may affect their pregnancy plans, and providing client-centered contraceptive care for those who need it. The OPA Zika toolkit provides resources to disseminate this information, which was seen as highly valuable to the states involved in OPA's meetings.
- •Working to ensure clinics have access to a broad range of contraceptive methods, including LARC, ideally on a same-day, onsite basis. This strategy can include building referral networks and accessing existing training resources.
- •Removing financial barriers to the provision of contraceptive services, including LARC, by encouraging state Medicaid programs to adopt reimbursement policies that were identified by CMCS and have been endorsed by CDC (Center for Medicaid and CHIP Services, 2016,Center for Medicaid and CHIP Services
State Medicaid payment approaches to improve access to long-acting reversible contraception.CMCS Informational Bulletin, Baltimore2016Centers for Disease Control and Prevention, 2016).Centers for Disease Control and Prevention (CDC)
The 6/18 Initiative: Prevent unintended pregnancy.
To accomplish these goals, state agencies will benefit from actively seeking collaboration with key stakeholders, such as health care provider groups, including those representing primary care providers, and others involved in family planning (e.g., the American Association of Family Physicians, Federally Qualified Health Centers, Title X grantees, Medicaid, Indian Health Service, the Veterans Administration hospitals, the American Association of Nurse Practitioners, and ACOG). Collaborative efforts should focus on sharing information related to Zika and identifying ways to expand contraceptive access throughout the state. States can also continue to learn from efforts in other jurisdictions to expand access to contraceptive care (
Rankin et al., 2016). To maximize the impact of these efforts, it is recommended that states not wait to plan and implement Zika-related family planning care until local mosquito-borne transmission occurs, both so that states are prepared to scale up public health efforts as needed if local transmission occurs, and to ensure that the risks associated with travel- and sex-associated cases of Zika are not ignored in the meantime.
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As these states and others continue to work to integrate family planning into their response to the Zika virus, it will be critically important to consider how to support these efforts financially, both through local and federal funding.
As states consider how to respond to the ongoing threat of Zika, we encourage public health decision makers to build on the efforts of the eight states described in this paper to collaboratively and efficiently leverage existing family planning resources, as well as preexisting efforts to expand quality family planning care, to help women and men achieve their reproductive goals in the context of the threat imposed by the Zika virus. These efforts have the potential to have the immediate impact of minimizing the negative consequences of the Zika virus in the United States, and also the longer term impact of developing a more robust and collaborative system of family planning service delivery that can meet the needs of women and men for reproductive health care and respond more efficiently and effectively to future public health threats that may warrant a family planning component in the response.
Further, the state collaborations, partnerships, and processes/protocols created in response to the Zika threat can be used as a model response to future public health threats with potential reproductive consequences, ensuring that state emergency response plans include family planning where appropriate.
The authors gratefully acknowledge the following individuals from the eight states described in this paper for the important work they are doing to expand contraceptive access in their states, and for their assistance in preparing this manuscript.
California: Nomsa Khalfani, Essential Access; Emili LaBass, California Primary Care Association.
Arizona: Brenda Thomas, Arizona Family Health; Ilana Addis, AZ ACOG chapter.
Georgia: Seema Csukas, Georgia Department of Public Health; Tracy Graham, Family Health Centers of Georgia; Melissa Kottke, Emory University School of Medicine; Melissa Reams, Georgia Association for Primary Health Care, Inc.
Florida: Shay Chapman and Susan Speake, Florida Department of Health; Robert W. Yelverton MD, Florida ACOG chapter.
Texas: Tracy Ayrhart, PhD, Kami E. Geoffray, JD, and Bernadette Mason, CPM, Women's Health & Family Planning Association of Texas.
South Carolina: Lisa Hobbs, Stephanie Derr, and Monty Robertson, South Carolina Department of Health and Human Services.
Mississippi: Katherine Farrington, Kathy Burk, Danielle Seale, Mississippi State Department of Health; Sonja Fuqua, Mississippi Primary Care Association.
Louisiana: Carolyn Wise, Louisiana Department of Health.
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Christine Dehlendorf, MD, MAS, is a family physician and Director of the Program in Woman-Centered Contraception at the University of California, San Francisco. Her research focuses on understanding and meeting women's needs for family planning and family planning care.
Loretta Gavin, PhD, MPH, is a senior Health Scientist at the U.S. Office of Population Affairs (OPA) whose recent work has focused on strengthening the quality of family planning services through the development and implementation of evidence-based clinical recommendations.
Jacki Witt, JD, MSN, WHNP-BC, is the Project Director for the Title X National Clinical Training Center for Family Planning. She focuses on contraception and HIV prevention in underserved populations and competency-based clinical education.
Susan Moskosky, MS, WHNP-BC, is the Acting Director for the U.S. Office of Population Affairs. Ms. Moskosky spent the first 15 years of her professional career providing family planning and other preventive health services and educating nurse practitioner students.
Published online: May 08, 2017
Accepted: March 20, 2017
Received in revised form: March 18, 2017
Received: December 16, 2016
Funding Statement: The work described here and the preparation of the manuscript was funded by OPA; the authors report no conflicts of interest.
© 2017 Jacobs Institute of Women's Health. Published by Elsevier Inc.