Study: Family Planning Services Need Better Integration in Primary Care
Rural areas need attention
There is a growing need for primary care providers (PCPs) to integrate family planning services into their practices, particularly in rural areas and other places where there is no access to OB/GYNs and family planning centers.1
“We did this study because it’s crucial to ensure everyone has access to family planning services, including contraception,” says Alex Schulte, lead study author and a PhD candidate at the UC Berkeley School of Public Health. “Contraception is extremely important, especially now at this point in time when many people live in states where there is no access to abortion procedures. [We] looked at general outpatient care settings, which include community health clinics and private physician practices. We know that when someone has a need related to family planning services, they can go to a clinic that specializes in those services — like Planned Parenthood — and that’s where the bulk of the research is focused.”
But there is a literature gap involving services provided outside of those settings, which is what Schulte and colleagues addressed.
“Our findings are that family planning services are more likely to be provided in urban instead of rural settings, and more in community health centers than private physician practices,” Schulte explains. “There’s a huge variation in who provides it and who doesn’t.”
Their findings suggest a need for more family practice providers to receive training on contraceptive counseling. Licensing boards should include this counseling in their requirements.
“In primary care visits, providers typically ask about diet. But they can also routinely ask about pregnancy intentions and offer contraceptive counseling, as needed,” Schulte says. “I think it should be standard practice.”
PCPs need additional education and training about reproductive healthcare partly because of the plethora of misinformation on contraception, she notes. This includes a belief, even among some physicians, that emergency contraception and/or intrauterine devices (IUDs) are abortifacient — despite all evidence to the contrary and the recent statement by the FDA that levonorgestrel is a nonabortifacient.2
Misinformation can fuel negative beliefs about contraceptive methods and decrease patient access, Schulte says. “I think standard training in medical school and with continuing education requirements would be one approach to combat this misinformation by providing trustworthy, scientifically accurate information about contraception,” she adds.
Accurate Information Is Crucial
All physicians need accurate information and at least some training in reproductive healthcare to combat a campaign of purposeful misinformation about contraception spread by the same groups that helped usher in the Dobbs decision, ending the constitutional right to abortion care.
For example, the president of Students for Life of America has said she wants contraceptives like IUDs and birth control pills to be made illegal. The group has built a social media campaign, spreading the lie that hormonal birth control is an abortifacient. Anti-abortion groups also are telling young people that hormonal birth control is toxic, and they are rebranding fertility awareness methods as “green sex.”3,4
These efforts are seeing some success in some abortion-ban states where insurers and providers have attempted to limit or block access to emergency contraception and other methods.2
There are other actions that would help expand reproductive healthcare to people in places with too few providers with that knowledge and too many obstacles. For example, states can allow nurses and other nonphysician providers to offer contraceptive care. They could expand referral networks, especially in rural areas, to close the gap in access.
“In some states, nonphysician providers can and do offer contraceptive counseling and some contraceptive services,” Schulte says. “What they offer has to do with the scope of practice and state licensing boards.”
Expanding nonphysician clinicians’ scope of practice can help fill the gap created by maternity and reproductive health deserts.
“The studies I’ve seen show that it is perfectly safe for nonphysician clinicians to offer these types of services,” Schulte explains. “I would encourage other states to expand the scope of practice so access can be expanded, and more types of clinicians can offer these services.”
It will help improve access if rural providers are part of a strong referral network and know where to send patients who need a service, such as reproductive healthcare, that they are unable to provide.
Raise Awareness to Barriers
There also should be greater awareness among physicians about how difficult it is for many women to obtain contraception care. Providers may think it is easy for patients to obtain the pill or some other form of contraception, Schulte says. Although the FDA has approved Opill, the first over-the-counter hormonal birth control pill, it will be months before this contraceptive is available in grocery stores and pharmacies. Rural areas may see an even longer lag time.
For other forms of contraception, women need access to a provider who can counsel them and provide their preferred method. They need insurance to cover the method, too. Although the Affordable Care Act mandates contraceptive coverage at no out-of-pocket cost, this still leaves out many people because of the Supreme Court’s decision to allow employers to opt out of contraceptive coverage if it goes against their corporate philosophy or religion. Also, women who are homeless, undocumented, or underage may not be able to access insurance for their contraceptives.
While family planning clinics typically provide most of the contraceptive options a patient might want, smaller physician’s offices may be unable to stock all the brands and types. If they need to order an IUD, injection, or patch, then patients will need to take off more time from school or work for another appointment. That is a barrier to their receiving contraceptive care.
“Above all, I think it’s extremely important for all providers to understand and respect patient autonomy and make sure patients’ desires are centered in their conversation and practices — especially around IUDs,” Schulte says. “There is research showing patients feel coerced into using an IUD or another long-acting reversible birth control.”
But if patients want an IUD, how can family physicians make it accessible? One way is to offer regional or online training for physicians who want to learn the procedure.
“Increase training and awareness for appropriate insertion techniques as well as regulatory barriers,” Schulte suggests. “Another option is to address the cost, the financial barriers that many patients need to overcome, and help patients get insurance.”
Access Is Necessary
Access to contraception is especially important in this era after the end of Roe v. Wade, when many states have made it difficult or impossible for women to end their pregnancies at local clinics.
“For those where abortion is not an option, they need access to contraception to live a life aligned with their goals and desires,” Schulte says. “Everyone has a right to own their reproductive futures and to live a healthy, vibrant life.”
Since this is a time in which full reproductive health access is restricted due to abortion bans, it is extremely important to expand access to the full scope of contraceptive services.
“To do that, we need to expand access to clinicians who can have the appropriate training to offer these services,” Schulte says.
REFERENCES
- Schulte A, Biggs MA. Association between facility and clinician characteristics and family planning services provided during U.S. outpatient care visits. Womens Health Issues 2023;S1049-3867(23)00128-7.
- Adashi EY, Cohen IG, Wilcox AJ. The FDA declares levonorgestrel a nonabortifacient — a 50-year saga takes a decisive turn. JAMA Health Forum 2023;4:e232257.
- Mostafa A, Butler K, Mieszkowski. The long campaign to turn birth control into the new abortion. Reveal. Oct. 8, 2022.
- Cauterucci C. Birth control is next. Slate. April 21, 2023.
There is a growing need for primary care providers to integrate family planning services into their practices, particularly in rural areas and other places where there is no access to OB/GYNs and family planning centers.
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