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- Providing Quality Family Planning Services (QFP) is a report that recommends how to provide family planning services so that people can: achieve their desired number and spacing of children, increase the chances that a baby will be born healthy, and improve their health even if they choose to not have children.
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Aug 6, 2024 · What services to offer in a family planning visit, including contraceptive services, pregnancy testing and counseling, helping clients achieve pregnancy, basic infertility services, preconception health services, and sexually transmitted disease services.
Entitled Providing Quality Family Planning Services 11 (QFP), we will describe how the recommendations were developed, summarize key points, and outline steps that will be taken to disseminate and increase their use by providers of family planning services.
- Lorrie Gavin, Susan Moskosky
- 2014/08
- 10.1089/jwh.2014.4865
The recommendations outline how to provide quality family planning services, which include contraceptive services, pregnancy testing and counseling, helping clients achieve pregnancy, basic infertility
- 1MB
- 60
- Overview
- Summary
- Introduction
- Methods
- Contraceptive Services
- Pregnancy Testing and Counseling
- Clients Who Want to Become Pregnant
- Basic Infertility Services
- Preconception Health Services
- Sexually Transmitted Disease Services
Please note: An update has been published for this report. To view the update, please click here.
Prepared by
Loretta Gavin, PhD,1 Susan Moskosky, MS,2 Marion Carter, PhD,1 Kathryn Curtis, PhD,1 Evelyn Glass, MSPH,2 Emily Godfrey, MD,1 Arik Marcell, MD,3 Nancy Mautone-Smith, MSW,2 Karen Pazol, PhD,1 Naomi Tepper, MD,1 Lauren Zapata, PhD1
1Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC
2Office of Population Affairs, US Department of Health and Human Services, Rockville, Maryland
3The Johns Hopkins University and the Male Training Center for Family Planning and Reproductive Health, Baltimore, Maryland
This report provides recommendations developed collaboratively by CDC and the Office of Population Affairs (OPA) of the U.S. Department of Health and Human Services (HHS). The recommendations outline how to provide quality family planning services, which include contraceptive services, pregnancy testing and counseling, helping clients achieve pregnancy, basic infertility services, preconception health services, and sexually transmitted disease services. The primary audience for this report is all current or potential providers of family planning services, including those working in service sites that are dedicated to family planning service delivery as well as private and public providers of more comprehensive primary care.
The United States continues to face substantial challenges to improving the reproductive health of the U.S. population. Nearly one half of all pregnancies are unintended, with more than 700,000 adolescents aged 15–19 years becoming pregnant each year and more than 300,000 giving birth. One of eight pregnancies in the United States results in preterm birth, and infant mortality rates remain high compared with those of other developed countries.
The United States continues to face challenges to improving the reproductive health of the U.S. population. Nearly half (49%) of all pregnancies are unintended (1). Although adolescent birth rates declined by more than 61% during 1991–2012, the United States has one of the highest adolescent pregnancy rates in the developed world, with >700,000 adolescents aged 15–19 years becoming pregnant each year and >300,000 giving birth (2,3). Approximately one of eight pregnancies in the United States results in a preterm birth, and infant mortality rates remain high compared with other developed countries (3,4). Moreover, all of these outcomes affect racial and ethnic minority populations disproportionately (1–4).
Family planning services can help address these and other public health challenges by providing education, counseling, and medical services (5). Family planning services include the following:
•providing contraception to help women and men plan and space births, prevent unintended pregnancies, and reduce the number of abortions;
•offering pregnancy testing and counseling;
•helping clients who want to conceive;
•providing basic infertility services;
Recommendations Development Process
The recommendations were developed jointly under the auspices of CDC's Division of Reproductive Health and OPA, in consultation with a wide range of experts and key stakeholders. More information about the processes used to conduct systematic reviews, the role of technical experts in reviewing the evidence, and the process of using the evidence to develop recommendations is provided (Appendix A). A multistage process was used to develop the recommendations that drew on established procedures for developing clinical guidelines (20,21). First, an Expert Work Group* was formed comprising family planning clinical providers, program administrators, and representatives from relevant federal agencies and professional medical associations to help define the scope of the recommendations. Next, literature about three priority topics (i.e., counseling and education, serving adolescents, and quality improvement) was reviewed by using the USPSTF methodology for conducting systematic reviews (22). The results were presented to three technical panels† comprising subject matter experts (one panel for each priority topic) who considered the quality of the evidence and made suggestions for what recommendations might be supported on the basis of the evidence. In a separate process, existing clinical recommendations on women's and men's preventive services were compiled from more than 35 federal and professional medical associations, and these results were presented to two technical panels of subject matter experts, one that addressed women's clinical services and one that addressed men's clinical services. The panels provided individual feedback about which clinical preventive services should be offered in a family planning setting and which clinical recommendations should receive the highest consideration. CDC and OPA used the input from the subject matter experts to develop a set of core recommendations and asked the Expert Work Group to review them. The members of the Expert Work Group were more familiar with the family planning service delivery context than the members of the Technical Panel and thus could better comment on the feasibility and appropriateness of the recommendations, as well as the supporting evidence. The Expert Work Group considered the core recommendations by using the following criteria: 1) the quality of the evidence; 2) the positive and negative consequences of implementing the recommendations on health outcomes, costs or cost-savings, and implementation challenges; and 3) the relative importance of these consequences, (e.g., the likelihood that implementation of the recommendation will have a substantial effect on health outcomes might be considered more than the logistical challenges of implementing it) (20). In certain cases, when the evidence from the literature reviews was inconclusive or incomplete, recommendations were made on the basis of expert opinion. Finally, CDC and OPA staff considered the individual feedback from Expert Work Group members when finalizing the core recommendations and writing the recommendations document. A description of how the recommendations link to the evidence is provided together with the rationale for the inclusion of each recommendation in this report (Appendix B). The evidence used to prepare these recommendations will appear in background papers that will be published separately. Resources that will help providers implement the recommendations will be provided through a web-based tool kit that will be available at http://www.hhs.gov/opa.
Audience for the Recommendations
The primary audience for this report is all providers or potential providers of family planning services to clients of reproductive age, including providers working in clinics that are dedicated to family planning service delivery, as well as private and public providers of more comprehensive primary care. Providers of dedicated family planning services might be less familiar with the specific recommendations for the delivery of preconception services. Providers of more comprehensive primary care might be less familiar with the delivery of contraceptive services, pregnancy testing and counseling, and services to help clients achieve pregnancy. This report can be used by medical directors to write clinical protocols that describe how care should be provided. Job aids and other resources for use in service sites are being developed and will be made available when ready through OPA's website (http://www.hhs.gov/opa). In this report, the term "provider" refers to any staff member who is involved in providing family planning services to a client. This includes physicians, physician assistants, nurse practitioners, nurse-midwives, nursing staff, and health educators. The term "service site" represents the numerous settings in which family planning services are delivered, which include freestanding service sites, community health centers, private medical facilities, and hospitals. A list of special terms used in this report is provided (Box 1). The recommendations are designed to guide general clinical practice; however, health-care providers always should consider the individual clinical circumstances of each person seeking family planning services. Similarly, these recommendations might need to be adapted to meet the needs of particular populations, such as clients who are HIV-positive or who are substance users.
Organization of the Recommendations
This report is divided into nine sections. An initial section provides an overview of steps to assess the needs of a client and decide what family planning services to offer. Subsequent sections describe how to provide each of the following services: contraceptive services, pregnancy testing and counseling, helping clients achieve pregnancy, basic infertility services, preconception health services, STD services and related preventive health services. A final section on quality improvement describes actions that all providers of family planning services should consider to ensure that services are of high quality. More detailed information about selected topics addressed in the recommendations is provided (Appendices A–F). These recommendations focus on the direct delivery of care to individual clients. However, parallel steps might need to be taken to maintain the systems required to support the provision of quality services for all clients (e.g., record-keeping procedures that preserve client confidentiality, procedures that improve efficiency and reduce clients' wait time, staff training to ensure that all clients are treated with respect, and the establishment and maintenance of a strong system of care coordination and referrals).
Providers should offer contraceptive services to clients who wish to delay or prevent pregnancy. Contraceptive services should include consideration of a full range of FDA-approved contraceptive methods, a brief assessment to identify the contraceptive methods that are safe for the client, contraceptive counseling to help a client choose a method of contraception and use it correctly and consistently, and provision of one or more selected contraceptive method(s), preferably on site, but by referral if necessary. Contraceptive counseling is defined as a process that enables clients to make and follow through on decisions about their contraceptive use. Education is an integral component of the contraceptive counseling process that helps clients to make informed decisions and obtain the information they need to use contraceptive methods correctly.
Key steps in providing contraceptive services, including contraceptive counseling and education, have been outlined (Box 3). These key steps are in accordance with the five principles of quality counseling (Appendix C). To help a client who is initiating or switching to a new method of contraception, providers should follow these steps. These steps most likely will be implemented iteratively when working with a client and should help clients adopt, change, or maintain contraceptive use.
Step 1. Establish and maintain rapport with the client. Providers should strive to establish and maintain rapport. Strategies to achieve these goals include the following:
•using open-ended questions;
•demonstrating expertise, trustworthiness, and accessibility;
•ensuring privacy and confidentiality;
Providers of family planning services should offer pregnancy testing and counseling services as part of core family planning services, in accordance with recommendations of major professional medical organizations, such as the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) (95–97).
Pregnancy testing is a common reason for a client to visit a provider of family planning services. Approximately 65% of pregnancies result in live births, 18% in induced abortion, and 17% spontaneous fetal loss (98). Among live births, only 1% of infants are placed for adoption within their first month of life (99).
The visit should include a discussion about her reproductive life plan and a medical history that includes asking about any coexisting conditions (e.g., chronic medical illnesses, physical disability, psychiatric illness) (95,96). In most cases, a qualitative urine pregnancy test will be sufficient; however, in certain cases, the provider may consider performing a quantitative serum pregnancy test, if exact hCG levels would be helpful for diagnosis and management. The test results should be presented to the client, followed by a discussion of options and appropriate referrals.
Options counseling should be provided in accordance with recommendations from professional medical associations, such as ACOG and AAP (95–97). A female client might wish to include her partner in the discussion; however, if a client chooses not to involve her partner, confidentiality must be assured.
Providers should advise clients who wish to become pregnant in accordance with the recommendations of professional medical organizations, such as the American Society for Reproductive Medicine (ASRM) (100).
Providers should ask the client (or couple) how long she or they have been trying to get pregnant and when she or they hope to become pregnant. If the client's situation does not meet one of the standard definitions of infertility (see "Basic Infertility Services"), then she or he may be counseled about how to maximize fertility. Key points are as follows:
•The client should be educated about peak days and signs of fertility, including the 6-day interval ending on the day of ovulation that is characterized by slippery, stretchy cervical mucus and other possible signs of ovulation.
•Women with regular menstrual cycles should be advised that vaginal intercourse every 1–2 days beginning soon after the menstrual period ends can increase the likelihood of becoming pregnant.
•Methods or devices designed to determine or predict the time of ovulation (e.g., over-the-counter ovulation kits, digital telephone applications, or cycle beads) should be discussed.
•It should be noted that fertility rates are lower among women who are very thin or obese, and those who consume high levels of caffeine (e.g., more than five cups per day).
Providers should offer basic infertility care as part of core family planning services in accordance with the recommendations of professional medical organizations, such as ACOG, ASRM, and the American Urological Association (AUA) (96,101,102).
Infertility commonly is defined as the failure of a couple to achieve pregnancy after 12 months or longer of regular unprotected intercourse (101). Earlier assessment (such as 6 months of regular unprotected intercourse) is justified for women aged >35 years, those with a history of oligo-amenorrhea (infrequent menstruation), those with known or suspected uterine or tubal disease or endometriosis, or those with a partner known to be subfertile (the condition of being less than normally fertile though still capable of effecting fertilization) (101). An early evaluation also might be warranted if risk factors of male infertility are known to be present or if there are questions regarding the male partner's fertility potential (102). Infertility visits to a family planning provider are focused on determining potential causes of the inability to achieve pregnancy and making any needed referrals to specialist care (101,102). ASRM recommends that evaluation of both partners should begin at the same time (101).
Providers of family planning services should offer preconception health services to female and male clients in accordance with CDC's recommendations to improve preconception health and health care (24).
Preconception health services are beneficial because of their effect on pregnancy and birth outcomes and their role in improving the health of women and men. The term preconception describes any time that a woman of reproductive potential is not pregnant but at risk of becoming pregnant, or when a man is at risk for impregnating his female partner.
Preconception health-care services for women aim to identify and modify biomedical, behavioral, and social risks to a woman's health or pregnancy outcomes through prevention and management. It promotes the health of women of reproductive age before conception, and thereby helps to reduce pregnancy-related adverse outcomes, such as low birthweight, premature birth, and infant mortality (24). Moreover, the preconception health services recommended here are equally important because they contribute to the improvement of women's health and well-being, regardless of her childbearing intentions. CDC recommends that preconception health services be integrated into primary care visits made by women of reproductive age, such as family planning visits (24).
In the family planning setting, providers may prioritize screening and counseling about preconception health for couples that are trying to achieve pregnancy and couples seeking basic infertility services. Women who are using contraception to prevent or delay pregnancy might also benefit from preconception health services, especially those at high risk of unintended pregnancy. A woman is at high risk of unintended pregnancy if she is using no method or a less effective method of contraception (e.g., barrier methods, rhythm, or withdrawal), or has a history of contraceptive discontinuation or incorrect use (38,39). A woman is at lower risk of unintended pregnancy if she is using a highly effective method, such as an IUD or implant, or has an established history of using methods of contraception, such as injections, pills, patch, or ring correctly and consistently (38,39). Clients who do not want to become pregnant should also be provided preconception health services, since they are recommended by USPSTF for the purpose of improving the health of adults.
Recommendations for improving the preconception health of men also have been identified, although the evidence base for many of the recommendations for men is less than that for women (103). This report includes preconception health services that address men as partners in family planning (i.e., both preventing and achieving pregnancy), their direct contributions to infant health (e.g., genetics), and their role in improving the health of women (e.g., through reduced STD/HIV transmission). Moreover, these services are important for improving the health of men regardless of their pregnancy intention.
In a family planning setting, all women planning or capable of pregnancy should be counseled about the need to take a daily supplement containing 0.4 to 0.8 mg of folic acid, in accordance with the USPSTF recommendation (Grade A) (104).
Providers should offer STD services in accordance with CDC's STD treatment and HIV testing guidelines (36,123,124). It is important to test for chlamydia annually among young sexually active females and for gonorrhea routinely among all sexually active females at risk for infection because they can cause tubal infertility in women if left untreated. Testing for syphilis, HIV/AIDS, and hepatitis C should be conducted as recommended (36,123,124). Vaccination for human papillomavirus (HPV) and hepatitis B are also important parts of STD services and preconception care (113).
STD services should be provided for persons with no signs or symptoms suggestive of an STD. STD diagnostic management recommendations are not included in these guidelines, so providers should refer to CDC's STD treatment guidelines (36) when caring for clients with STD symptoms. STD services include the following steps, which should be provided at the initial visit and at least annually thereafter:
Step 1. Assess: The provider should discuss the client's reproductive life plan, conduct a standard medical history and sexual health assessment (see text box above), and check immunization status. A pelvic exam is not indicated in patients with no symptoms suggestive of an STD.
Step 2. Screen: A client who is at risk of an STD (i.e., sexually active and not involved in a mutually monogamous relationship with an uninfected partner) should be screened for HIV and the other STDs listed below, in accordance with CDC's STD treatment guidelines (36) and recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings (123). Clients also should follow CDC's recommendations for testing for hepatitis C (124), and the Advisory Committee on Immunization Practice's recommendations on reproductive health-related immunizations (113). It is important to follow these guidelines both to ensure that clients receive needed services and to avoid unnecessary screening.
Chlamydia
For female clients, providers should screen all sexually active women aged ≤25 years for chlamydia annually, in addition to sexually active women aged >25 years with risk factors for chlamydia infection (36). Women aged >25 years at higher risk include sexually active women who have a new or more than one sex partner or who have a partner who has other concurrent partners. Females with chlamydia infection should be rescreened for re-infection at 3 months after treatment. Pregnant women should be screened for chlamydia at the time of their pregnancy test if there might be delays in obtaining prenatal care (36).
This concentric circle diagram of Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs (QFP), lays out a framework for family planning services within the context of related preventive health services and other preventive health services.
This report summarizes updated recommendations released from the time QFP was issued in April 2014 through the end of 2015. Recommendations are based on newly published find-ings or revisions in recommended best practices. Updates that have implications for clinical practice are highlighted (Box).
In April 2014, CDC published “Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs” (QFP), which describes the scope of services that should be offered in a family planning visit and how to provide those services (e.g., periodicity of screening, which persons are in need of services, etc.) ...
