Clients of Title X programs have greater access to a wide range of contraceptive methods, although reach has been limited by federal funding, state laws, and the Trump-era gag rule.1
When federal funding and new rules created access obstacles to Title X programs, the number of people served by the program dropped from 4.5 million in 2011 to 1.4 million in 2021.1
“One of the things I’m most concerned about with contraceptive access in the United States and with reproductive healthcare is how much access and quality is determined by the ZIP code for where you live,” says Maria Rodriguez, MD, MPH, a professor of obstetrics and gynecology and the director of the Center for Women’s Health at Oregon Health & Science University. “Access to quality evidence-based reproductive healthcare varies depending on where you live. When you have access to a Title X clinic, people are more likely to have their choice of all the different contraceptive methods we have.”
A study by Rodriguez and colleagues revealed that people receiving contraception care from non-Title X clinics had lower proportions of receiving long-acting reversible contraception (LARC) methods, nonoral hormonal methods, and extended supplies of oral contraceptives.1
“What’s special about Title X is it has clear rules and parameters around it, and it’s updated with evidence-based guidelines,” Rodriguez explains. “There is funding for people to have more training on the newest forms of contraception and [provision of] 12 months of short-acting hormonal contraception.”
The biggest drawback to Title X is that it depends on federal funding and is politically vulnerable, Rodriguez notes. This vulnerability was clear after the 2016 federal election ushered in the Trump administration, which aggressively attacked Title X. The Trump administration stopped the Teen Pregnancy Prevention Program funding in 2017 and decreased Title X’s funding period from three years to seven months in August 2018. Then, the administration made a rule change that ended a requirement that Title X programs provide all FDA-approved contraceptive methods. It also removed confidentiality protection for adolescents and implemented the gag rule that stopped referrals to and information about abortion. These changes resulted in more than 1,000 family planning clinics leaving the Title X program. Although the Biden administration revoked the 2019 rule change, rebuilding Title X programs will take many years.1
Title X programs are an affordable place for people to obtain contraceptives when they lack insurance coverage. “Any patient with health insurance is likely to have no copay [and] full contraceptive coverage,” says Nicole Smith, PhD, study co-author and executive director of Montanans for Choice. Previously, Smith worked for Blue Mountain Clinic, a primary care provider and abortion provider in Montana.
But uninsured patients, including people who lack legal resident documentation, are the ones who struggle to obtain contraception, especially the methods that cost more upfront — including LARC, such as intrauterine devices (IUDs) and implants.
Title X programs can help these patients, but non-Title X programs have to access internal funds to subsidize the cost of contraceptives or charge patients for the contraception, Smith notes. “The Title X network has been underfunded for decades. We’re operating in a resource-scarce environment, and people’s interest in using contraception has been changing,” she says. “We need ongoing analysis and investigation to continue to center the needs of patients.”
The study by Rodriguez, Smith, and a colleague showed that people accessing Title X programs use a fuller range of contraception options when compared with non-Title X sites. “Prior research indicated that Title X sites offered a broader range of contraceptive services and adolescent-friendly policies and practices,” says lead study author Rebecca Wells, PhD, MHSA. Wells’s research work on this topic was conducted when she was a professor at The University of Texas School of Public Health. “Our expectation was that Title X would be associated with more contraceptive use. We wanted to look at the full range of contraceptive options because different people prefer different things.”
The full range of options includes barrier contraceptives and time-based methods. Wells, Smith, and Rodriguez also assessed the proportion of people who received more than three months of an oral contraceptive. They found there was no statistically significant difference between barrier and time-based contraceptive methods in the Title X group vs. the non-Title X group.
Wells took this to be a positive result. “It means Title X providers were not discouraging [those] methods. It suggests there was respect for all options, and all options were supported,” she says.
However, there was a significant difference in LARC use and patients prescribed longer supplies of oral contraceptives. Title X clients were more likely to receive more than a three-month supply of oral contraceptives (42% for Title X clients and 20% for non-Title X clients).
People accessing contraception through Title X were more likely to use LARC. LARC was used by 26% to 30% of Title X clients vs. 16% for non-Title X clients.
“Service at Title X sites was positively associated with using LARC,” Wells says. “That was a consistent pattern. It makes sense because the Title X program funds, supports, and requires sites to provide these most complex contraceptive services.”
The study period of 2015-2017 preceded the Supreme Court’s decision to overturn Roe v. Wade. But even in a new reproductive justice landscape where millions of women no longer have access to abortion care in their states, Title X and other family planning clinics need to maintain the focus on what patients want and need in contraceptive care.
“In an environment where we no longer have guaranteed access to legalized abortion care, we need to not coerce patients into using methods just because we want them on more highly effective methods,” Smith says. “We need to encourage them to use the method they want to use — if they want to use something at all.” But it also is important to ensure all people capable of pregnancy can access any contraceptive option they may desire, she adds.
The reproductive health safety net should be strengthened in states where there are abortion bans, Rodriguez says. “It’s an important time to help people meet their reproductive goals,” she says.
More attention should be paid to people whose health could be harmed if they become pregnant, including those with chronic illnesses. Contraception access is critical for this population, and hospitals and emergency departments could provide some contraceptive counseling when they see anyone capable of pregnancy.
“It’s a basic thing we should be doing — checking in on people [capable of pregnancy] when they are interacting with the healthcare system,” Rodriguez says.
Providers in Title X and non-Title X programs must be trained and comfortable with providing same-day LARC. This is important for people who have to drive a long way to the clinic and cannot afford to take off much time from work. “Make sure they’re given a full range of options, and they have full access in their state,” Smith advises. “In Montana, we have legal access — but you have to drive up to seven hours to get to a clinic if you live in eastern Montana."
This means more federal and state funding of Title X programs. “The most obvious policy change could be increasing funding for Title X,” Wells says. “The funding has decreased as the population has increased, so adequate and predictable funding is one policy option.”
Another is to invest in Title X service areas where people have limited resources and limited reproductive care options, Wells adds. “There are increasing numbers of people in contraceptive deserts,” she says. “Situating Title X in those areas would have a high impact — and would be hard to do.”
Earlier research found that contraceptive deserts were increasing after the Trump administration imposed dramatic restrictions on Title X programs and forced the withdrawal of many family planning organizations.2
Reproductive care access and policies vary widely in the United States in the Dobbs decision environment. “The type of policy environment we’re in right now depends on the state where you’re living,” Rodriguez says. “We’ve turned back the clock on federal protection of abortion, and many states have passed legislation that is harmful to women capable of pregnancy.”
Some states, like Oregon, have protected sexual and reproductive health rights, but action is needed. “It’s important we do all we can locally and regionally to protect [contraception and abortion] access,” Rodriguez says.
For example, more states could pass a bill like Oregon’s 2017 Reproductive Health Equity Act, which codifies abortion in the constitution and provides no-cost abortion coverage for people with low income. It also promotes gender-affirming care.3
“We’ve seen an influx of people coming into Oregon for abortion care,” Rodriguez says. “We’ve passed legislation implementing protections for reproductive health providers in the state, so no other state can make a case against me and other doctors.”
Oregon Health & Science University partnered with philanthropists to provide abortion training for OB/GYN residents from restricted settings where they are unable to learn abortion care.
“Contraception is a fundamental aspect of people’s reproductive health, and we need to make sure it’s broadly available to people wherever they may live,” Rodriguez says.
Some low-hanging fruit for most communities and settings are to ensure Opill, the over-the-counter birth control pill, is stocked and widely available in pharmacies and stores, and to ensure that prescription contraceptives are available at pharmacies.
“Take a systematic look at where we have access issues and what measures we can use to improve it,” Rodriguez says. “Can we partner with a larger clinic to do more telemedicine and get more referrals done? Can we have emergency contraception available?”
Title X programs should be a first line of defense because they serve the most vulnerable populations, including minors, people who are undocumented, and those who have no income and no insurance.
“It’s truly a program that services people who otherwise would not receive contraceptive care, and it provides it well,” Wells says.
REFERENCES
- Wells R, Smith NK, Rodriguez MI. Contraception use by Title X clients and clients of other providers, 2015-2019. Womens Health Issues 2024;34:59-65.
- Smith CW, Kreitzer RJ, Kane KA, Saunders TM. Contraception deserts: The effects of Title X rule changes on access to reproductive health care resources. Politics & Gender 2022;18:672-707.
- Oregon Health Authority. What is the Reproductive Health Equity Act (HB 3391)? 2024. https://www.oregon.gov/oha/ph/...