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Availability of Services Related to Achieving Pregnancy in U.S. Publicly Funded Family Planning Clinics

Published:September 04, 2019DOI:https://doi.org/10.1016/j.whi.2019.07.005

      Abstract

      Background

      Recognizing that quality family planning services should include services to help clients who want to become pregnant, the objective of our analysis was to examine the distribution of services related to achieving pregnancy at publicly funded family planning clinics in the United States.

      Methods

      A nationally representative sample of publicly funded clinics was surveyed in 2013–2014 (n = 1615). Clinic administrators were asked about several clinical services and screenings related to achieving pregnancy: basic infertility services, reproductive life plan assessment, screening for body mass index, screening for sexually transmitted diseases, provision of natural family planning services, infertility treatment, and primary care services. The percentage of clinics offering each of these services was compared by Title X funding status; prevalence ratios (PRs) and 95% confidence intervals (CIs) were estimated after adjusting for clinic characteristics.

      Results

      Compared to non-Title X clinics, Title X clinics were more likely to offer reproductive life plan assessment (adjusted PR [aPR], 1.62; 95% CI, 1.42–1.84), body mass index screening for men (aPR, 1.10; 95% CI, 1.01–1.21), screening for sexually transmitted diseases (aPRs ranged from 1.21 to 1.37), and preconception health care for men (aPR, 1.10; 95% CI, 1.01–1.20). Title X clinics were less likely to offer infertility treatment (aPR, 0.55; 95% CI, 0.40–0.74) and primary care services (aPR, 0.74; 95% CI, 0.68–0.80) and were just as likely to offer basic infertility services, preconception health care services for women, natural family planning, and body mass index screening in women.

      Conclusions

      The availability of selected services related to achieving pregnancy differed by Title X status. A follow-up assessment after publication of national family planning recommendations is underway.
      Services related to infertility and achieving pregnancy are less frequently recognized as family planning services, but are critical components of sexual and reproductive health (
      • Starrs A.M.
      • Ezeh A.C.
      • Barker G.
      • Basu A.
      • Bertrand J.T.
      • Blum R.
      • Ashford L.S.
      Accelerate progress-sexual and reproductive health and rights for all: Report of the Guttmacher-Lancet Commission.
      ). Although there has been documented success of programs focused on contraception, maternal and newborn health, and human immunodeficiency virus (HIV)/AIDS in countries around the world, other aspects of sexual and reproductive health, such as infertility, have been neglected (
      • Asemota O.A.
      • Klatsky P.
      Access to infertility care in the developing world: The family promotion gap.
      ,
      • Place J.M.
      • Litwack I.
      • Vann S.
      Is infertility as visible as it needs to be given its importance to women's health? Results from a review of women's health journals.
      ,
      • Starrs A.M.
      • Ezeh A.C.
      • Barker G.
      • Basu A.
      • Bertrand J.T.
      • Blum R.
      • Ashford L.S.
      Accelerate progress-sexual and reproductive health and rights for all: Report of the Guttmacher-Lancet Commission.
      ). For much of the world, including the United States, high-income persons are more likely to have access to infertility services (
      • Asemota O.A.
      • Klatsky P.
      Access to infertility care in the developing world: The family promotion gap.
      ,
      • Chandra A.
      • Copen C.E.
      • Stephen E.H.
      Infertility service use in the United States: Data from the National Survey of Family Growth, 1982-2010.
      ,
      • Farland L.V.
      • Collier A.Y.
      • Correia K.F.
      • Grodstein F.
      • Chavarro J.E.
      • Rich-Edwards J.
      • Missmer S.A.
      Who receives a medical evaluation for infertility in the United States?.
      ,
      • Jain T.
      Socioeconomic and racial disparities among infertility patients seeking care.
      ).
      The 2014 Providing Quality Family Planning Services: Recommendations of CDC and the US Office of Population Affairs (QFP) defined, for the first time, a core set of family planning services for women and men (
      • Gavin L.
      • Moskosky S.
      • Carter M.
      • Curtis K.
      • Glass E.
      • Godfrey E.
      • Zapata L.
      Providing quality family planning services: Recommendations of CDC and the US Office of Population Affairs.
      ). These recommendations include services to help clients who want to become pregnant or have difficulty conceiving (e.g., infertility), and encompass fertility education and counseling, medical assessments, and providing basic infertility services (
      Basic Infertility Services Resources
      These resources support Quality Family Planning Recommendations related to providing basic infertility services.
      ,
      • Gavin L.
      • Moskosky S.
      • Carter M.
      • Curtis K.
      • Glass E.
      • Godfrey E.
      • Zapata L.
      Providing quality family planning services: Recommendations of CDC and the US Office of Population Affairs.
      ). The QFP also recommends additional services, including screening and treatment for sexually transmitted diseases (STDs) to prevent tubal infertility, and preconception health services, which can improve the overall health of women and men prior to conception (
      ACOG Committee Opinion number 313, September 2005
      The importance of preconception care in the continuum of women's health care.
      ,
      • Johnson K.
      • Posner S.F.
      • Biermann J.
      • Cordero J.F.
      • Atrash H.K.
      • Parker C.S.
      • Curtis M.G.
      Recommendations to improve preconception health and health care--United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care.
      ). These recommendations are further supported by the Centers for Disease Control and Prevention's National Public Health Action Plan for the Detection, Prevention, and Management of Infertility, published in 2014 (
      Centers for Disease Control and Prevention
      National Public Health Action Plan for the detection, prevention, and management of infertility.
      ).
      Although the QFP recommendations apply to all family planning providers, integrating services to achieve pregnancy within publicly funded family planning clinics can increase access to these services for individuals with low incomes, in particular. The Title X Family Planning Program, administered by the U.S. Office of Population Affairs, is the only federal program dedicated exclusively to providing comprehensive family planning and related preventive health services and information to individuals who desire and need them, with priority given to serving individuals with low incomes. It is therefore well-positioned to address the fertility needs of low-income populations.
      The objective of our analysis was to examine the baseline distribution of services related to achieving pregnancy at publicly funded family planning clinics in the United States before publication of the 2014 QFP recommendations. We examined service provision by whether or not the clinic received funding under the Title X Family Planning Program. We also examined how the provision of basic infertility services was associated with other pregnancy-achieving services provided in the clinic.

      Methods

      Data Source

      We used data from a nationally representative sample of publicly funded U.S. clinics that provided family planning services in 2010. Two thousand non-Title X and 2,000 Title X-funded clinics were randomly selected from a database maintained by the Guttmacher Institute and were surveyed during 2013–2014, before the QFP was published. Clinic administrators were asked to report on clinic characteristics, types of clients served, and the services and screenings offered at their clinics. No further details or instructions on what exact procedures constituted each service were provided. Surveys could be completed on paper or online, and several follow-up reminders were sent. Details of the study's survey methodology have been previously published (
      • Carter M.W.
      • Gavin L.
      • Zapata L.B.
      • Bornstein M.
      • Mautone-Smith N.
      • Moskosky S.B.
      Four aspects of the scope and quality of family planning services in US publicly-funded health centers: Results from a survey of health center administrators.
      ,
      • Robbins C.L.
      • Gavin L.
      • Zapata L.B.
      • Carter M.W.
      • Lachance C.
      • Mautone-Smith N.
      • Moskosky S.B.
      Preconception care in publicly funded U.S. clinics that provide family planning services.
      ,
      • Robbins C.L.
      • Gavin L.
      • Carter M.W.
      • Moskosky S.B.
      The link between reproductive life plan assessment and provision of preconception care at publicly funded health centers.
      ).
      We calculated the response rate using a method first proposed by the Council of American Survey Research Organizations (
      Council of American Survey Research Organizations
      On the definition of response rates. Special report.
      ), which was later defined in detail by the
      American Association for Public Opinion Research
      Standard definitions: Final dispositions of case codes and outcome rates for surveys website.
      (method 4) (Final Dispositions of Case Codes and Outcome Rates for Surveys Website) and has been used by the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System since the survey's inception (
      Centers for Disease Control and Prevention
      Behavioral Risk Factor Surveillance System.
      ). This response rate method applies the proportion of eligible respondents in the subgroup with known eligibility information (i.e., responded to survey) to the subgroup with unknown eligibility (i.e., did not respond to survey). The proportion that did not respond to the survey and were considered ineligible were then excluded from the response rate denominator. The final response rate was 49.3% (n = 1,615). Institutional review board approval was not needed for this project because it was determined to be public health practice.

      Services Related to Achieving Pregnancy

      We operationalized the provision of pregnancy-achieving services using 11 items measured on the survey that identified either 1) services were provided on-site or 2) clinics had a written protocol in place for a given service. Items were selected based on our assessment of services that fell within the QFP recommendations for care that should be provided to clients who want to become pregnant, and included those that assessed fertility intentions, enhanced fertility-achieving behaviors, and prevented and/or treated infertility or causes of infertility. We included primary care services given they may provide a more comprehensive health assessment compared with family planning services (
      American Academy of Family Physicians
      Primary care.
      ), and primary care providers may be more likely to refer patients to specialized infertility services and prescribe infertility drugs (e.g., clomiphene) (
      • Lindsay T.J.
      • Vitrikas K.R.
      Evaluation and treatment of infertility.
      ). Natural family planning was included in our analysis because this family planning method can also be used to calculate a woman's fertile window and maximize her chances of conceiving (
      • Mu Q.
      • Fehring R.J.
      Efficacy of achieving pregnancy with fertility-focused intercourse.
      ).
      For our analysis, pregnancy-achieving services provided on-site included the provision of preconception health care, basic infertility services, infertility treatment, primary care services, and natural family planning. To assess preconception health care and basic infertility services, clinic administrators were asked to report how frequently these services were provided in the past three months to men and women, separately, and were given the response options of never, rarely, occasionally, and frequently. Response options were dichotomized for our analyses into never (no) versus rarely, occasionally, and frequently (yes) because we wanted to assess whether or not the services were available at the clinic; we assumed if they were ever provided then they were available to clients. For infertility treatment, primary care services, and natural family planning, clinic administrators were queried on the types of partnerships they had with providers who offered these selected services. The five response choices were combined into two groups: 1) we offer this on site; co-located with those who do; or our parent organization provides this, versus 2) contract, or other written agreement; informal relationships with provider(s) who do this; and referral only. These questions on type of established partnerships referred to services provided in general, not for male and female clients separately.
      Clinic administrators were also asked whether screening protocols or clinical recommendations were in place. They were first asked about their clinic's clinical recommendations for select on-site, routine screening during initial or follow-up family planning visits, for women and men, separately, and whether or not these were specified in a written protocol. For our analysis, we included specific health conditions or recommendations related to fertility intentions or infertility prevention, as outlined in the QFP. Specifically, we examined whether protocols for screening for underweight or obesity (by assessing body mass index) and STDs (i.e., chlamydia, gonorrhea, syphilis, and HIV) were in place at the facility, given their respective associations with polycystic ovarian syndrome (
      ACOG Practice Bulletin No. 194: Polycystic ovary syndrome
      ), adverse pregnancy outcomes (
      • Leeper C.
      • Lutzkanin 3rd., A.
      Infections during pregnancy.
      ), and pelvic inflammatory disease (
      • Brunham R.C.
      • Gottlieb S.L.
      • Paavonen J.
      Pelvic inflammatory disease.
      ), which increases the risk of infertility. The response options for each screening protocol item were yes or no and were asked separately for screening services for men and women. Additionally, we assessed whether a written protocol existed for assessing a client's reproductive life plan, which includes asking the client questions such as whether or not he or she wants to have (more) children and when. The response options to having a written protocol for reproductive life plan assessment were yes or no, and this question was not sex specific.

      Clinic Characteristics

      Clinic type (community health center, health department, reproductive health focused, and hospital/other) was obtained from the information captured in the Guttmacher Institute database. The other clinic characteristics used in our analysis were reported by the clinic administrator and included clinical focus (reproductive, primary care health, or other), annual family planning caseload category (<1,000, 1,000–4,999, and ≥5000 clients), percentage of family planning clients within age groups (<20, 20–29, 30–44, ≥45), percentage of family planning clients who were male, and clinic setting (mostly urban/suburban, mostly rural, and combination rural/urban).

      Statistical Analyses

      We calculated the distribution of clinic characteristics across the sample and by Title X funding status. We then assessed the distribution of services related to achieving pregnancy across the sample and by Title X funding status, and calculated prevalence ratios and 95% confidence intervals (CIs) comparing Title X with non–Title X-funded clinics using predicted margins from logistic regression. We calculated adjusted prevalence ratios (aPRs) to account for differences between Title X and non-Title X clinics in terms of clinical focus, annual family planning caseload, the percentage of clients age 20–29 years (the age group that most varied by Title X funding status), the percentage of male clients, and rural–urban setting. We compared clinics by Title X funding status because clinics that receive Title X funding must comply with program requirements and regulations, which may result in a higher standard for family planning service provision than clinics that do not receive such funding. Title X clinics are also periodically subject to site visits, which assess compliance with program requirements and regulations, and receive regular training from Title X-funded national training centers (
      Title X Family Planning Program Requirements, U.S. Office of Population Affairs.
      ).
      We then specifically examined the reported provision of basic infertility services (for men and women separately) by the other 10 reported pregnancy-achieving services and screening protocols in place. We performed this analysis because the provision of basic infertility services most directly relates to helping a client achieve pregnancy, and to further understand what types of pregnancy-achieving services offered in clinics corresponded with a greater likelihood of providing basic infertility services. Unadjusted and aPRs for provision of basic infertility services were then calculated using predicted margins from logistic regression. The adjusted model included clinic characteristics, as above; however, the percentage of family planning clients age 30–44 years (rather than limiting to age 20–29 years) was included to adjust for potential differences in the need for basic infertility services across clinics, because a higher proportion of older clients could represent greater need for infertility services in a particular clinic.
      All analyses were weighted to represent U.S. publicly funded health centers offering family planning services. We used SAS (SAS Institute, Cary, NC) and SUDAAN (RTI International, Research Triangle Park, NC) survey procedures to account for the complex survey design. Analyses included all observations with nonmissing data for the variables under study.

      Results

      Among publicly funded clinics that provided family planning services in the United States in 2013–2014, approximately one-half received Title X funding and one-half did not. Title X-funded clinics were more likely to be located in health departments, have a family planning/reproductive health focus, have larger annual family planning caseloads, and be located in more rural settings (Table 1). In addition, Title X-funded clinics reported a younger age of family planning clients and seeing fewer male clients compared with non-Title X clinics.
      Table 1Distribution of Health Center Characteristics Across a Sample of Publicly Funded Clinics, US (2013–2014)
      Clinic Characteristics
      Information was missing for the following characteristics: clinic focus (n = 8), annual family planning caseload (n = 87), age of family planning clients (<20, n = 240; 20–29, n = 263; 30–44, n = 294; ≥45, n = 385), gender of family planning clients (n = 524), setting (n = 17).
      AllTitle X FundingNo Title X Funding
      n (%, SE)n (%, SE)n (%, SE)
      Total1,6151,045 (49.3%)570 (50.7%)
      Type of clinic
       Community health center427 (36.6, –)110 (13.8, –)317 (58.7, –)
       Health department684 (31.4, –)637 (57.4, –)47 (6.1, –)
       Reproductive health focus168 (9.1, –)133 (12.9, –)35 (5.4, –)
       Hospital/other336 (23.0, –)165 (16.0, –)171 (29.8, –)
      Clinic focus
       Family planning/reproductive health782 (40.2, 0.91)668 (62.5, 1.30)114 (18.5, 1.27)
       Primary (general health) care619 (48.4, 0.92)217 (23.2, 1.07)402 (72.8, 1.49)
       Other206 (11.4, 0.77)153 (14.3, 1.05)53 (8.7, 1.13)
      Annual family planning caseload
       <1,000767 (50.6, 1.29)493 (48.6, 1.51)274 (52.7, 2.11)
       1,000–4,999564 (36.3, 1.28)388 (38.9, 1.54)176 (33.5, 2.06)
       ≥5,000197 (13.2, 0.89)125 (12.5, 0.99)72 (13.8, 1.48)
      Age (years) of family planning clients
      Percentage reflects the median percentage reported by respondents for each category.
       <201,375 (25.8, 0.47)921 (24.0, 0.55)454 (20.0, 0.89)
       20–291,352 (50.0, 0.43)909 (44.0, 0.48)443 (35.0, 0.85)
       30–441,321 (23.7, 0.30)890 (20.0, 0.35)431 (20.0, 0.55)
       ≥451,230 (11.2, 0.34)838 (6.0, 0.31)392 (10.0, 0.79)
      Gender of family planning clients
      Percentage reflects the median percentage reported by respondents for each category.
       Men1,091 (12.5, 0.51)756 (5.0, 0.51)335 (10.0, 1.13)
      Setting
       Mostly urban/suburban459 (30.7, 1.20)265 (26.5, 1.32)194 (34.9, 1.99)
       Mostly rural800 (48.2, 1.27)549 (52.1, 1.48)251 (44.5, 2.06)
       Combination rural/urban339 (21.0, 1.07)223 (21.4, 1.28)116 (20.6, 1.71)
      Abbreviation: SE, standard error.
      Note: Standard errors cannot be calculated for these two variables, because they were used to define the sample strata.
      Information was missing for the following characteristics: clinic focus (n = 8), annual family planning caseload (n = 87), age of family planning clients (<20, n = 240; 20–29, n = 263; 30–44, n = 294; ≥45, n = 385), gender of family planning clients (n = 524), setting (n = 17).
      Percentage reflects the median percentage reported by respondents for each category.
      Overall, Title X-funded clinics were more likely to offer the following services compared to non-Title X clinics: reproductive life plan assessment (76% vs. 35%), body mass index screening for women (85% vs. 79%), STD screenings (e.g., chlamydia [women]: 94% vs. 69%; syphilis [men]: 85% vs. 54%), and natural family planning services (83% vs. 74%) (Table 2). Title X-funded clinics were less likely to offer infertility treatment (11% vs. 22%) and primary care services (34% vs. 82%), and were just as likely as non-Title X clinics to offer basic infertility services for women (both approximately 66%) and men (42%–47%), preconception health care for women (both approximately 94%) and men (both approximately 69%), and body mass index screening for men (both approximately 73%). After adjustment for clinic characteristics, all of these differences were attenuated but remained statistically significant (aPRs ranged from 0.55 to 1.62), with the exception of body mass index screening for women and natural family planning services; in addition, the following two services were found to be more prevalent among Title X-funded clinics: preconception health care for men (aPR, 1.10; 95% CI, 1.01–1.20) and body mass index screening for men (aPR, 1.10; 95% CI, 1.01–1.21) (Table 2).
      Table 2Association Between Pregnancy-Achieving Services Provided on Site and Screening Protocols, by Title X Funding Status
      Services Provided on Site
      Information was missing for the following services or routine screening: basic infertility services (women n = 51/1,615; men n = 57/1,615), preconception health care (women n = 38/1,615; men n = 58/1,615), natural family planning (n = 19/1,615), infertility treatment (n = 21/1,615), primary care (n = 21/1,615), reproductive life plan assessment (n = 245/1,615), body mass index (women n = 183/1,615; men n = 300/1,615), chlamydia (women n = 181/1,615; men n = 296/1,615), gonorrhea (women n = 180/1,615; men n = 296/1,615), syphilis (women n = 194/1,615; men n = 307/1,615), and HIV (women n = 190/1,615; men n = 303/1,615).
      AllTitle X FundingNo Title X FundingTitle X Funding vs. No Title X Funding
      (N = 1,615)(n = 1,045)(n = 570)
      % (SE)% (SE)% (SE)PR (95% CI)APR
      Adjusted for type of clinic, annual family planning caseload, the percentage of female family planning clients 20–29, the percentage of male family planning clients, and setting. Adjusted models were fit on a smaller number of observations (range, 74–100 fewer) than unadjusted models owing to missing information on covariates.
      (95% CI)
      Basic infertility services
       Women65.9 (1.25)66.2 (1.47)65.6 (2.01)1.01 (0.94–1.09)1.07 (0.97–1.17)
       Men44.6 (1.31)42.0 (1.54)47.2 (2.11)0.89 (0.79–1.00)1.07 (0.94–1.23)
      Preconception health care
       Women94.0 (0.65)94.9 (0.70)93.1 (1.09)1.02 (0.99–1.05)1.01 (0.98–1.04)
       Men69.1 (1.20)68.4 (1.45)69.9 (1.92)0.98 (0.91–1.05)1.10 (1.01–1.20)
      p < .05.
      Natural family planning
       All78.4 (1.11)83.1 (1.17)73.8 (1.88)1.13 (1.06–1.19)
      p < .05.
      1.06 (1.00–1.14)
      Infertility treatment
       All16.3 (0.97)10.5 (0.94)21.9 (1.69)0.48 (0.38–0.61)
      p < .05.
      0.55 (0.40–0.74)
      p < .05.
      Primary care
       All58.0 (0.86)33.7 (1.20)81.9 (1.23)0.41 (0.38–0.44)
      p < .05.
      0.74 (0.68–0.80)
      p < .05.
      Recommendations for routine screening in written protocol
      Information was missing for the following services or routine screening: basic infertility services (women n = 51/1,615; men n = 57/1,615), preconception health care (women n = 38/1,615; men n = 58/1,615), natural family planning (n = 19/1,615), infertility treatment (n = 21/1,615), primary care (n = 21/1,615), reproductive life plan assessment (n = 245/1,615), body mass index (women n = 183/1,615; men n = 300/1,615), chlamydia (women n = 181/1,615; men n = 296/1,615), gonorrhea (women n = 180/1,615; men n = 296/1,615), syphilis (women n = 194/1,615; men n = 307/1,615), and HIV (women n = 190/1,615; men n = 303/1,615).
       Reproductive life plan assessment
      All56.9 (1.24)76.4 (1.37)34.9 (2.13)2.19 (1.93–2.47)
      p < .05.
      1.62 (1.42–1.84)
      p < .05.
       Body mass index
      Women82.2 (1.09)85.0 (1.17)79.3 (1.85)1.07 (1.02–1.13)
      p < .05.
      1.06 (0.99–1.13)
      Men73.1 (1.26)72.9 (1.50)73.4 (2.06)0.99 (0.93–1.06)1.10 (1.01–1.21)
      p < .05.
       Chlamydia
      Women82.2 (1.09)94.0 (0.78)69.3 (2.11)1.36 (1.28–1.44)
      p < .05.
      1.21 (1.14–1.29)
      p < .05.
      Men75.2 (1.23)89.3 (1.04)59.3 (2.32)1.50 (1.39–1.63)
      p < .05.
      1.33 (1.22–1.44)
      p < .05.
       Gonorrhea
      Women81.0 (1.11)93.3 (0.82)67.7 (2.13)1.38 (1.29–1.47)
      p < .05.
      1.21 (1.14–1.29)
      p < .05.
      Men74.8 (1.24)89.3 (1.05)58.9 (2.33)1.52 (1.40–1.65)
      p < .05.
      1.33 (1.23–1.45)
      p < .05.
       Syphilis
      Women73.8 (1.21)87.8 (1.07)58.9 (2.23)1.49 (1.38–1.61)
      p < .05.
      1.27 (1.18–1.38)
      p < .05.
      Men69.8 (1.30)84.5 (1.22)53.5 (2.38)1.58 (1.44–1.73)
      p < .05.
      1.37 (1.24–1.51)
      p < .05.
       HIV
      Women80.2 (1.13)92.0 (0.89)67.4 (2.13)1.36 (1.28–1.46)
      p < .05.
      1.22 (1.14–1.30)
      p < .05.
      Men75.2 (1.24)88.5 (1.09)60.6 (2.32)1.46 (1.35–1.58)
      p < .05.
      1.33 (1.22–1.45)
      p < .05.
      Abbreviations: APR, adjusted prevalence ratio; PR, prevalence ratio; SE, standard error.
      Information was missing for the following services or routine screening: basic infertility services (women n = 51/1,615; men n = 57/1,615), preconception health care (women n = 38/1,615; men n = 58/1,615), natural family planning (n = 19/1,615), infertility treatment (n = 21/1,615), primary care (n = 21/1,615), reproductive life plan assessment (n = 245/1,615), body mass index (women n = 183/1,615; men n = 300/1,615), chlamydia (women n = 181/1,615; men n = 296/1,615), gonorrhea (women n = 180/1,615; men n = 296/1,615), syphilis (women n = 194/1,615; men n = 307/1,615), and HIV (women n = 190/1,615; men n = 303/1,615).
      Adjusted for type of clinic, annual family planning caseload, the percentage of female family planning clients 20–29, the percentage of male family planning clients, and setting. Adjusted models were fit on a smaller number of observations (range, 74–100 fewer) than unadjusted models owing to missing information on covariates.
      p < .05.
      Providing basic infertility services was related to having several other related services in place (Table 3). Adjusted analyses found that providing basic infertility services for women was more likely if the clinic also reported providing preconception health care services for women (aPR, 3.54; 95% CI, 2.03–6.17), natural family planning (aPR, 1.34; 95% CI, 1.18–1.53), infertility treatment (aPR, 1.33; 95% CI, 1.22–1.45), and primary care services (aPR, 1.22; 95% CI, 1.09–1.36) (Figure 1). Adjusted analyses found that providing basic infertility services for men was more likely if the clinic also reported providing preconception health care services for men (aPR, 4.42; 95% CI, 3.32–5.88), natural family planning (aPR, 1.37; 95% CI, 1.12–1.67), infertility treatment (aPR, 1.28; 95% CI, 1.08–1.51), primary care services (aPR, 1.46; 95% CI, 1.22–1.74), body mass index screening for men (aPR, 1.46; 95% CI, 1.22–1.76), and HIV screening for men (aPR, 1.25; 95% CI, 1.03–1.51) (Figure 1).
      Table 3Prevalence of Delivery of Basic Infertility Services by Pregnancy-Achieving Services Provided on Site and Screening Protocols
      Services Provided on Site
      Information was missing for the following services or routine screening for women: preconception health care (women n = 10/1,564; men n = 18/1,558), natural family planning (women n = 5/1,564; men n = 5/1,558), infertility treatment (women n = 7/1,564; men n = 7/1,558), primary care (women n = 7/1,564; men n = 7/1,558), reproductive life plan assessment (women n = 213/1,564; men n = 209/1,558), body mass index (women n = 151/15,64; men n = 262/1,558), chlamydia (women n = 151/1,564; men n = 259/1,558), gonorrhea (women n = 150/1,564; men n = 259/1,558), syphilis (women n = 164/1,564; men n = 270/1,558), and HIV (women n = 160/1,564; men n = 266/1,558).
      Provided Basic Infertility Services to WomenProvided Basic Infertility Services to Men
      (n = 1,564)

      % (SE)
      (n = 1,558)

      % (SE)
      Preconception health care
      These services were assessed for men and women separately, corresponding with the basic infertility services separately assessed for men and women.
       Yes69.3 (1.24)59.2 (1.57)
       No16.3 (3.96)12.9 (1.62)
      Natural family planning
       Yes70.4 (1.34)47.5 (1.46)
       No50.3 (2.98)34.2 (2.87)
      Infertility treatment
       Yes85.0 (2.56)61.3 (3.46)
       No62.4 (1.39)41.5 (1.40)
      Primary care
       Yes70.4 (1.72)53.5 (1.89)
       No60.0 (1.76)32.3 (1.64)
      Recommendations for routine screening in written protocol
      Information was missing for the following services or routine screening for women: preconception health care (women n = 10/1,564; men n = 18/1,558), natural family planning (women n = 5/1,564; men n = 5/1,558), infertility treatment (women n = 7/1,564; men n = 7/1,558), primary care (women n = 7/1,564; men n = 7/1,558), reproductive life plan assessment (women n = 213/1,564; men n = 209/1,558), body mass index (women n = 151/15,64; men n = 262/1,558), chlamydia (women n = 151/1,564; men n = 259/1,558), gonorrhea (women n = 150/1,564; men n = 259/1,558), syphilis (women n = 164/1,564; men n = 270/1,558), and HIV (women n = 160/1,564; men n = 266/1,558).
       Reproductive life plan assessment
      Yes66.8 (1.65)42.0 (1.73)
      No64.1 (2.26)45.8 (2.35)
       Body mass index
      These services were assessed for men and women separately, corresponding with the basic infertility services separately assessed for men and women.
      Yes66.7 (1.43)49.8 (1.70)
      No66.1 (3.17)33.6 (2.65)
       Chlamydia
      These services were assessed for men and women separately, corresponding with the basic infertility services separately assessed for men and women.
      Yes66.6 (1.39)46.4 (1.59)
      No66.2 (3.46)43.1 (3.20)
       Gonorrhea
      These services were assessed for men and women separately, corresponding with the basic infertility services separately assessed for men and women.
      Yes66.3 (1.40)46.6 (1.59)
      No67.5 (3.33)43.0 (3.18)
       Syphilis
      These services were assessed for men and women separately, corresponding with the basic infertility services separately assessed for men and women.
      Yes66.4 (1.47)46.0 (1.66)
      No67.4 (2.79)45.0 (2.86)
       HIV
      These services were assessed for men and women separately, corresponding with the basic infertility services separately assessed for men and women.
      Yes67.4 (1.40)47.7 (1.60)
      No64.2 (3.32)39.8 (3.15)
      Information was missing for the following services or routine screening for women: preconception health care (women n = 10/1,564; men n = 18/1,558), natural family planning (women n = 5/1,564; men n = 5/1,558), infertility treatment (women n = 7/1,564; men n = 7/1,558), primary care (women n = 7/1,564; men n = 7/1,558), reproductive life plan assessment (women n = 213/1,564; men n = 209/1,558), body mass index (women n = 151/15,64; men n = 262/1,558), chlamydia (women n = 151/1,564; men n = 259/1,558), gonorrhea (women n = 150/1,564; men n = 259/1,558), syphilis (women n = 164/1,564; men n = 270/1,558), and HIV (women n = 160/1,564; men n = 266/1,558).
      These services were assessed for men and women separately, corresponding with the basic infertility services separately assessed for men and women.
      Figure thumbnail gr1
      Figure 1Adjusted prevalence ratios for the delivery of basic infertility services by pregnancy-achieving services provided on site and screening protocols prevalence ratios and 95% CIs are shown for women (A) and men (B) on the x-axis using the log scale. Prevalence ratios were adjusted for type of clinic, annual family planning caseload, the percentage of female patients ages 30 to 44 reported, and setting. Adjusted models were fit on a slightly smaller number of observations (range, 0–22 fewer) than displayed in due to missing information on covariates. Preconception care, body mass index screening, and sexually transmitted diseases screening for women. Preconception care, body mass index screening, and sexually transmitted diseases screening for men.

      Discussion

      Family planning providers offer a unique opportunity to help clients achieve pregnancy and prevent infertility and, in doing so, provide a range of services to optimize clients’ ability to achieve their desired timing, number, and spacing of children. Studies are limited on the provision of services to help clients achieve pregnancy and address infertility among publicly funded clinics (
      • Zolna M.R.
      • Frost J.J.
      Publicly funded family planning clinics in 2015: Patterns and trends in service delivery practices and protocols.
      ), yet these services remain an essential part of quality family planning (
      • Gavin L.
      • Moskosky S.
      • Carter M.
      • Curtis K.
      • Glass E.
      • Godfrey E.
      • Zapata L.
      Providing quality family planning services: Recommendations of CDC and the US Office of Population Affairs.
      ). Our study characterizes the delivery of these services in publicly funded clinics before the publication of the 2014 QFP recommendations and provides a baseline assessment for comparison with findings from a follow-up survey currently underway (
      Federal Register
      Monitoring changes in attitudes and practices among family planning providers and clinics.
      ).
      Although previous analyses of these study data have examined several of the preconception care services included in our analysis (
      • Robbins C.L.
      • Gavin L.
      • Zapata L.B.
      • Carter M.W.
      • Lachance C.
      • Mautone-Smith N.
      • Moskosky S.B.
      Preconception care in publicly funded U.S. clinics that provide family planning services.
      ,
      • Robbins C.L.
      • Gavin L.
      • Carter M.W.
      • Moskosky S.B.
      The link between reproductive life plan assessment and provision of preconception care at publicly funded health centers.
      ), we were specifically interested in identifying the full set of services that may offer opportunities to prevent infertility and/or enhance fertility in family planning settings serving persons with low incomes. In particular, we found that a high proportion of publicly funded clinics reported that they provided basic infertility services for women (66%), whereas a lower proportion reported this for men (45%). Infertility treatment was infrequently reported (16%), especially among Title X-funded clinics (11%) as compared with non-Title X clinics (22%), which may reflect the different client populations served in these two settings. In contrast, the provision of natural family planning counseling was prevalent overall (78%) and higher in Title X (83%) compared with non–Title X-funded (74%) clinics.
      In one of the few studies to examine the scope of pregnancy-achieving and infertility services among publicly funded clinics providing family planning services,
      • Zolna M.R.
      • Frost J.J.
      Publicly funded family planning clinics in 2015: Patterns and trends in service delivery practices and protocols.
      surveyed publicly funded clinics in 2015 using the same sampling frame as this study (Guttmacher Institute database) and assessed the provision of a range of family planning services, including infertility counseling and testing (
      • Zolna M.R.
      • Frost J.J.
      Publicly funded family planning clinics in 2015: Patterns and trends in service delivery practices and protocols.
      ). The
      • Zolna M.R.
      • Frost J.J.
      Publicly funded family planning clinics in 2015: Patterns and trends in service delivery practices and protocols.
      survey was conducted after publication of the QFP (2014), which could have led to higher reports of selected services provided; however, the administration and wording on the questions were also different, so it is difficult to tease apart the effect of survey timing from study design differences.
      In contrast with our study,
      • Zolna M.R.
      • Frost J.J.
      Publicly funded family planning clinics in 2015: Patterns and trends in service delivery practices and protocols.
      found a lower proportion of clinics reported offering infertility counseling (49%) and testing (55%) than we found for basic infertility services reported in our study (66% in women). This finding may be due to differences in how these measures were assessed, because basic infertility services could be interpreted to include a broader array of services than just infertility counseling and testing. The delivery of natural family planning instruction was comparable between the two studies, with an 83% prevalence in the
      • Zolna M.R.
      • Frost J.J.
      Publicly funded family planning clinics in 2015: Patterns and trends in service delivery practices and protocols.
      study compared with a 78% prevalence found in our study. Interestingly,
      • Zolna M.R.
      • Frost J.J.
      Publicly funded family planning clinics in 2015: Patterns and trends in service delivery practices and protocols.
      noted a substantial increase in clinics reporting natural family planning instruction from 2003 (54%), which we were unable to measure, because our survey was first administered in 2013–2014.
      Prevalence estimates of STD and HIV testing (98% for chlamydia and gonorrhea, 94% for syphilis and HIV) from the
      • Zolna M.R.
      • Frost J.J.
      Publicly funded family planning clinics in 2015: Patterns and trends in service delivery practices and protocols.
      study were consistent with prevalence estimates of STD testing reported in a separate study of federally qualified health centers surveyed in 2011 (95% for HIV testing, 96% for STD testing) (
      • Wood S.
      • Beeson T.
      • Bruen B.
      • Goldberg D.G.
      • Mead H.
      • Shin P.
      • Rosenbaum S.
      Scope of family planning services available in Federally Qualified Health Centers.
      ). Both studies reported higher estimates than were found in our study (range, 74%–82% in women; 70%–75% in men). Additionally,
      • Zolna M.R.
      • Frost J.J.
      Publicly funded family planning clinics in 2015: Patterns and trends in service delivery practices and protocols.
      reported a higher prevalence of body mass index screening (96%) compared with our study (82% in women, 73% in men). Again, differences could be due to the wording of the questions, timing of the survey in relation to publication of the QFP, and the clinics included in each survey.
      When comparing all 11 components of fertility-related services and after adjustment for clinic differences, we found some services varied considerably by Title X funding status. In particular, basic infertility services (for women and men), preconception care services (for women), body mass index screening (for women), and natural family planning counseling did not differ significantly, whereas the provision of infertility treatment and primary care services were less likely in Title X compared with non–Title X-funded clinics. Conversely, we found that recommendations for routine screening of pregnancy intentions (i.e., reproductive life plan assessment), preconception health care (for men), and screening for risk factors for infertility and adverse pregnancy outcomes (i.e., STD and body mass index screening for men) were more likely in Title X compared with non–Title X-funded clinics. Previous studies using these data have also shown enhanced preconception care service delivery in Title X-funded clinics (
      • Robbins C.L.
      • Gavin L.
      • Zapata L.B.
      • Carter M.W.
      • Lachance C.
      • Mautone-Smith N.
      • Moskosky S.B.
      Preconception care in publicly funded U.S. clinics that provide family planning services.
      ), which was attributed to institutional support from the Office of Population Affairs to Title X grantees to promote preconception care and training in reproductive life plan assessment. Although we adjusted for some differences between the two clinic categories, the differences we found in services provided by Title X funding status may also reflect the unique needs of the clients attending each type of clinic.
      A unique contribution of our study was our examination of the types of services associated with reported provision of basic infertility services, which we found included natural family planning, primary care, preconception health care, body mass index screening (in men only), HIV screening (in men only), and infertility treatment. The association was strongest for the provision of preconception health care services, which is consistent with the idea that preconception care not only optimizes pregnancy health, but can support individuals in achieving pregnancy. These findings indicate that providing basic infertility services may be occurring through the provision of several related services. However, these findings may also reflect heterogeneity and uncertainty in what constitutes basic infertility services and other fertility-related services.
      Our study has limitations that may affect the interpretation of our study findings. First, the survey did not ask about specific details when assessing pregnancy-achieving or basic infertility care services, such as whether clients were educated on tracking peak fertility days or asked about difficulty in achieving pregnancy. Second, the survey was not designed to assess pregnancy achieving and/or infertility services specifically; we operationalized the provision of these services using 11 items measured on the survey, which relied on relationships established in the literature on the connection between specific services, such as STD screening and fertility. Third, services were self-reported by clinic administrators and may be subject to bias that would affect interpretation of findings; for example, the services and response options were undefined beyond the information provided in the survey and may be interpreted differently by respondents and/or misclassified relative to QFP definitions. However, we would not anticipate that questions would be interpreted or classified differently by Title X funding status or other types of services, because the survey was administered identically across clinics. Fourth, the Council of American Survey Research Organizations response rate was approximately 50%, which could have introduced selection bias, but is typical of other health provider surveys (
      • McLeod C.C.
      • Klabunde C.N.
      • Willis G.B.
      • Stark D.
      Health care provider surveys in the United States, 2000-2010: A review.
      ). Weights were applied to ensure national representativeness of the sample, despite missing responses. Fifth, our adjusted models included covariates that we determined were predictors of the outcome under study, but there may still be residual bias due to both unmeasured and measured factors. Last, there was missing information for a number of items throughout the survey, leading to a varying number of observations for specific analyses. For the follow-up survey underway, efforts are being made to reduce missing information for each item.

      Implications for Practice and/or Policy

      Together with the existing literature, our study's findings indicate that publicly funded clinics providing family planning services offer an under-recognized resource for helping clients to achieve pregnancy and prevent infertility among low-income populations. Recommendations included in the QFP can help clients to achieve pregnancy by maximizing fertility through counseling, STD prevention and treatment, and preconception health, and by addressing infertility through providing basic services and treatment.
      As outlined in the QFP, providers should counsel clients who want to become pregnant and inquire how long the client or couple has been trying to become pregnant. If the client or couple does not fit the standard definition of infertility, they may be counseled on how to maximize their ability to conceive as described in the QFP (
      Basic Infertility Services Resources
      These resources support Quality Family Planning Recommendations related to providing basic infertility services.
      ,
      • Gavin L.
      • Moskosky S.
      • Carter M.
      • Curtis K.
      • Glass E.
      • Godfrey E.
      • Zapata L.
      Providing quality family planning services: Recommendations of CDC and the US Office of Population Affairs.
      ). Such counseling includes advising women with regular menstrual cycles that unprotected vaginal intercourse every 1–2 days beginning soon after their menstrual period ends can increase the likelihood of becoming pregnant; educating clients about peak days and signs of fertility and methods they can use to predict the time of ovulation; and noting that fertility rates are lower among women who are very thin or have obesity and among those with certain diets and lifestyles (
      ASRM Committee Opinion
      Optimizing natural fertility.
      ). Providers should also offer basic infertility services if a client or couple meets the definition of infertility, which is failure to achieve pregnancy after 12 months or more of regular unprotected intercourse or, for women older than 35 years, after 6 months of regular, unprotected intercourse.
      Additional opportunities for family planning providers to address achieving pregnancy and infertility services include the provision of preconception health services, because these can improve pregnancy and birth outcomes, as well as the overall health of women and men. Preconception health care services for women seek to identify and modify social, behavioral, and biomedical risks to a woman's health or pregnancy outcomes via prevention and management (
      ACOG Committee Opinion number 313, September 2005
      The importance of preconception care in the continuum of women's health care.
      ,
      • Johnson K.
      • Posner S.F.
      • Biermann J.
      • Cordero J.F.
      • Atrash H.K.
      • Parker C.S.
      • Curtis M.G.
      Recommendations to improve preconception health and health care--United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care.
      ). Thus, preconception health screening and counseling should also be prioritized among clients who want to become pregnant or those seeking basic infertility services.
      In terms of the Title X Family Planning Program, the higher prevalence we found for screening for fertility intentions and infertility risk factors in Title X-funded clinics indicates that they may provide an initial point of care for individuals wanting to conceive; however, additional referrals and links to infertility treatment and other related services, beyond basic infertility services, may be needed for clients wanting to conceive or who had delays in conceiving. Additionally, specific services provided by clinics, such as natural family planning counseling, preconception health care, primary care, or infertility treatment may already be meeting some of this demand.

      Conclusions

      Services related to achieving pregnancy and infertility at publicly-funded family planning clinics can help address these needs among low-income populations in the United States. Although an under-recognized component of quality family planning, these services are available either directly, through basic infertility services, or indirectly, through STD screening and preconception health services. Offering these services at all publicly funded family planning clinics can help people to achieve their desired number and spacing of children, and lead to improved health outcomes.

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      Biography

      Ana Carolina Loyola Briceno, MPH, is a Health Scientist with the Office of Population Affairs, U.S. Department of Health and Human Services. Her research interests include family planning, quality improvement, and health systems improvement.
      Katherine A. Ahrens, PhD, MPH, is an epidemiologist and Assistant Research Professor in the Public Health Program at the University of Southern Maine, Muskie School of Public Service. Her research interests include maternal and child health, with a focus on family planning.
      Susan B. Moskosky, MS, WHNP-BC, is Deputy Director of the Office of Population Affairs, U.S. Department of Health and Human Services. Her research focuses on quality improvement for family planning service delivery and contraceptive access.
      Marie E. Thoma, PhD, MHS, is an Assistant Professor in the Department of Family Science in the School of Public Health at the University of Maryland. Her research focuses on population-based methodologies for assessing gynecologic health, family planning, and infant health.