Abstract
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However, a solely health-oriented framing of family planning does not sufficiently capture the social and political context of efforts to control fertility historically, globally, or currently in the United States. Historically, family planning information and contraceptive methods were restricted as part of attempts to enforce moral or social imperatives regarding sexuality. Provision of contraceptive services was considered acceptable only in medical settings. 4 –6 In the same era, contraceptive services were subsidized and made available in low-income and minority communities, even when other health services were not, because of a recognized public interest in population control. Unfortunately, sterilizations performed without informed consent were sometimes included among these fertility control activities. 7,8 Globally, family planning has been framed as a component of human rights, because control over fertility promotes women's self-determination and protects against discrimination. The Title X family planning program, the federal funding stream in the United States that supports the provision of family planning services to low-income women and men in a mix of local sites, has been viewed in this context as an initiative that enhances reproductive autonomy and supports individual economic well-being and educational attainment. 9
The current debate over whether the Affordable Care Act requirement that health insurance include coverage for contraception infringes on the religious liberties of those who believe birth control is immoral illustrates the failure of the effort to depoliticize contraception by framing it in terms of health. 10 In fact, a health framing of contraception can actually be used to challenge efforts to support the broad availability of comprehensive family planning services when provided in specialized settings. As a case in point, antiabortion activists continue to pressure federal and state policy makers to exclude Planned Parenthood as a legitimate recipient of Title X and Medicaid family planning funds, and to direct these funds instead to community health centers and other safety net general healthcare providers, with the argument that the other providers offer a broader range of other services. 11,12
The article by Marion Carter and her CDC colleagues, “Referral Practices Among US Publicly Funded Health Centers that Offer Family Planning Services,” in this issue, should be read in this context. 13 To provide a baseline to measure improvements in meeting CDC's family planning quality recommendations, the authors surveyed publicly funded family planning providers to assess the quality of the referrals made for their clients with general healthcare needs. Active referrals, in which providers make appointments at the referral site for their clients, contact clients about the referral outcomes, and/or contact the referral source to find out whether the client was seen, are considered higher quality practices than passive referrals, where the client is provided with a directory or a specific name of a referral source, and asked about the referral at the next visit.
About half of the respondents to this survey were Title X-funded providers, and the remainder received other public funds. Less than a third of the responding sites reported frequently doing all three of the active referral practices, with Title X-funded sites overall, and health department, hospital-based and Planned Parenthood sites specifically, less likely to report frequently using active referral practices, compared with community health centers and other healthcare providers. Adjustments for larger patient volume, rural location, being part of an insurance network, and using electronic health records accounted for the difference by Title X status, but even with these adjustments, Planned Parenthood and hospital-based clinics were less likely to use active referral practices. In their discussion, the authors suggest that structural factors, including importantly whether other types of healthcare services are available at the family planning site, help to account for these referral patterns. The authors also note that other research has shown that Planned Parenthood sites offer a higher quality of family planning services than other types of sites.
Referrals from family planning care sites to other healthcare providers are essential, as many of these sites do not offer primary care, many clients do not have insurance coverage for general healthcare, and, based on responses to the National Survey of Family Growth, 63% of public family planning clients report that the family planning site is their usual source of medical care. 14 However, other CDC recommendations for quality family planning care are also important. These include assessing clients' reproductive health needs when they seek care for other conditions, offering a full spectrum of approved contraceptive methods and supporting the correct use of effective methods, addressing barriers to contraceptive use, and screening and referral of women experiencing intimate partner violence to appropriate intervention services. 3
As a consequence of the social and political context, the range of sites that now provide publicly supported family planning services have different baseline capabilities to meet the varied CDC recommendations. So long as these providers are isolated from each other and the rest of the healthcare system, clients will experience both uneven access to comprehensive reproductive healthcare and missed opportunities to receive needed general healthcare services. Robust referral practices, both from family planning sites (as documented here) and to family planning specialty sites from general healthcare providers, could shift the diverse capacities of the family planning provider community from a weakness to a strength. Carter and colleagues' study is one component of a baseline assessment that should be used to build such a system.
Footnotes
Author Disclosure Statement
No competing financial interests exist.