While there is encouraging evidence that the rate of unintended pregnancies in the United States is declining, the rates remain higher for medically underserved populations. Federally Qualified Health Centers (FQHCs), such as AltaMed, are one of the largest providers of family planning services for medically underserved populations. Therefore, FQHC's, especially those receiving Title X funding, are seeking ways to reduce the rates of unintended pregnancies for the populations they serve. Long-Acting Reversible Contraceptives (LARCs) are the most effective form of birth control. There are currently five approved LARC devices available, they have few contraindications, and most women are appropriate candidates. Therefore, according to the American College of Obstetricians and Gynecologists (ACOG) recommendations, providers should encourage patients to consider LARC usage when counseling about family planning. Despite the significant benefits of LARCs, there is evidence to suggest that patients encounter barriers when attempting to receive a LARC. Previously identified barriers include inadequate stock at clinics, provider discomfort with the procedure, and inaccurate provider training and knowledge. AltaMed has not yet assessed whether or not these or other systemic barriers to LARC access exist at their clinics.
Our goal is to examine LARC uptake and sterilization rates among AltaMed Family Planning clinics. We will also focus on examining differences in rates by county, clinic site, and patient demographics. Furthermore, we will compare delays in LARC placement between clinics with high and low uptake of effective contraceptive methods.
To implement this study, we examined Title X data for rates of LARC uptake/sterilization among eligible women by clinic, county, race/ethnicity, age, and patient insurance status. We defined eligible women, based on ACOG guidelines, as girls and women between ages 12-50 excluding those seeking pregnancy, currently pregnant, using abstinence, or whose method is unknown. Title X data is collected from monthly family planning visits for men and women from each of the family planning sites. In order to determine delays in LARC placement, we randomly identified a subset of women who had a LARC placed from the electronic records of 2 clinics (one clinic with high LARC uptake and one with lower LARC uptake). We reviewed the charts of 20 patients from each clinic. We then examined how long it took for a LARC to be placed after it was requested by a patient and determined reasons for LARC placement delay when possible.
From our initial data collection, we found that AltaMed Family Planning Clinics have high rates of ineffective contraception use among eligible women. For example, at one of the high performing clinics (Huntington Beach) 40% of eligible patients currently use a barrier or none method. While the lowest performing clinic (1st Street) has a rate of 58%. Across all AltaMed Family Planning Clinic sites, 29.7% (N = 14144) of eligible patients are currently using a LARC. Hispanic women have a LARC utilization rate of 30.5 % (12393) compared to 24.9% (N = 1663) for non-Hispanic women. The LARC utilization by insurance type was as follows: 29.6% for Public Health Insurance, 28.8 % for Private Health Insurance and 30.4% for Uninsured. Cross-sectional analysis from chart reviews at two sites is still preliminary.
Long-acting reversible contraceptives play a key role in reducing the rate of unintended pregnancies. Through our study, we demonstrated that AltaMed offers LARCs at all of its family planning sites but can improve utilization rates. We recognize that there are likely barriers to LARC utilization but further studies are required to clearly identify barriers to LARC placement. Furthermore, we would need to explore provider and patient perception of LARCs.