Title X funding does not always mean the most accessible services for family planning clients.

Services available to family planning clients may differ substantially by key characteristics of the facilities. For example, in a sample of facilities in four states, (1) Title X-funded sites were more likely than those without Title X funding to offer emergency contraception, but were less likely to have extended hours. All Planned Parenthood sites, but only 47-74% of others, offered emergency contraception. This type of facility was also the most likely to have weekend hours, but the least likely to accommodate the language needs of minority populations.

Researchers analyzed survey responses from 526 sites that provide services to the public regardless of clients' ability to pay. These facilities were located in four geographically diverse states (Alabama, Ohio, Oklahoma and Washington) and included local health department clinics, federally qualified health centers, Planned Parenthood sites and other facility types (hospital outpatient departments and freestanding women's health centers). The 20-question survey asked about sites' service provision in 2000. The investigators conducted chi-square tests to examine relationships between measures of service availability and site characteristics. Forty percent of the facilities were local health department clinics, 30% were federally qualified health centers and 15% each were Planned Parenthood facilities and other types of facilities. More than half received Title X funding (55%), and nearly all (94%) were Medicaid providers.

All sites offered the pill. Ninety-eight percent offered injectable contraceptives and 85% offered less commonly available family planning methods, such as diaphragms, implants and sterilization. Two-thirds offered emergency contraception, and nearly half offered primary care services. Midlevel practitioners (midwives or nurse practitioners) were on staff at 91% of sites, registered nurses at 81% and physicians at 62%. Only 31% of sites had social workers on staff.

More than two-thirds of the sites were open full-time, or more than 35 hours per week. One-quarter were open on weekends, and half offered evening hours. Clients at about half of all sites waited less than one week for an appointment; similarly, at about half of facilities, waiting times were typically less than 30 minutes. More than eight in 10 sites provided transportation assistance or were accessible via public transportation.

Most facilities offered educational materials in multiple languages (89%) and translation services (87%) to better serve their minority clients. Seven in 10 reported that their staff members' racial and ethnic mix matched that of their clients, and almost nine in 10 believed their staff was culturally competent.

The services and staff available differed significantly by type of facility. For example, all Planned Parenthood sites, but only 7983% of others, offered less commonly available contraceptives, and 97% of federally qualified health centers provided primary care services, versus 1-60% of others. All Planned Parenthood sites also offered emergency contraception, compared with 47% of federally qualified health centers, 60% of local health departments and 74% of other sites. Physicians were on staff at 93% of federally qualified health centers; this proportion was much lower elsewhere (3873%). All Planned Parenthood sites had midlevel practitioners, compared with 7994% of all other sites. Planned Parenthood sites were the least likely, and health department sites the most likely, to have social workers on staff (9% and 41%, respectively).

Nine in 10 federally qualified health centers were open full-time, compared with no more than two-thirds of other sites. Sixty percent of Planned Parenthood sites offered weekend hours, as did 35% of federally qualified health centers, 2% of local health department clinics and 28% of other sites. Clients waited less than 30 minutes to be seen at 75% of facilities classified as "other" and at 48-58% of the remaining types of facilities. Seven in 10 local health department clinics and nine in l0 sites in all other categories were accessible via public transportation or gave clients transportation assistance.

Nearly all federally qualified health centers (94-99%) provided educational materials, translation services, culturally competent staff, and staff with the same racial and ethnic mix as clients. The proportions were lower among local health department clinics (5187%) and Planned Parenthood sites (7275%), but were generally as high at other sites (76-96%).

Title X funding was also correlated with most of the measures of accessibility. Notably, sites with Title X funding were more likely than others to provide emergency contraception (73% vs. 53%), the injectable (99% vs. 96%) and less commonly available contraceptives (90% vs. 78%). However, they were less likely than those without it to offer primary care services; to be open fulltime, in the evening or on weekends; and to have services tailored for minorities.

Almost every measure studied varied by state. Among the most striking differences were in the proportions of facilities receiving Title X funding (80% in Oklahoma, compared with 41-56% in the other states) and in the proportions providing emergency contraception (20% in Alabama, compared with 91% in Washington).

According to the researchers, the results suggest that despite high levels of Title X funding, facilities run by local health departments or Planned Parenthood may not be the most accessible source of family planning services. Local health department clinics predominated in the sample, but offered limited service, staff and hours. Planned Parenthood sites offered a range of contraceptives, extended hours and transportation assistance, but were the least likely to be culturally competent. The investigators propose that federally qualified health centers, which generally provide primary care, focus more on family planning by providing emergency contraception and other contraceptives routinely, and offering family planning counseling to all women of childbearing age. "It may be appropriate," the researchers conclude, "to rethink the pattern of provision of publicly supported family planning [services]."

REFERENCE

(1.) Klerman LV et al., Accessibility of family planning services: impact of structural and organizational factors, Maternal and Child Health Journal, 2007, 11(1):19-26.