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Morbidity and Mortality Weekly Report

Recommendations and Reports / Vol. 63 / No. 4 April 25, 2014
Providing Quality Family Planning Services

Recommendations of CDC and the U.S. Office of Population Affairs
Continuing Education Examination available at http://www.cdc.gov/mmwr/cme/conted.html.
U.S. Department of Health and Human Services

Centers for Disease Control and Prevention
Recommendations and Reports
CONTENTS
Introduction.............................................................................................................1
Methods.....................................................................................................................3
Contraceptive Services.........................................................................................7
Pregnancy Testing and Counseling.............................................................. 13
Clients Who Want to Become Pregnant...................................................... 14
Basic Infertility Services..................................................................................... 15
Preconception Health Services...................................................................... 16
Sexually Transmitted Disease Services........................................................ 18
Related Preventive Health Services.............................................................. 20
Summary of Recommendations for Providing Family Planning and
Related Preventive Health Services............................................................ 21
Conducting Quality Improvement................................................................ 21
Conclusion............................................................................................................. 25
Appendix A............................................................................................................ 30
Disclosure of Relationship
Appendix B............................................................................................................ 35
CDC, our planners, content experts, and their spouses/partners
Appendix C............................................................................................................ 45 wish to disclose that they have no financial interests or other
Appendix D............................................................................................................ 47 relationships with the manufacturers of commercial products,
Appendix E............................................................................................................ 48 suppliers of commercial services, or commercial supporters.
Appendix F............................................................................................................ 51 Planners have reviewed content to ensure there is no bias.
The MMWR series of publications is published by the Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC),
U.S. Department of Health and Human Services, Atlanta, GA 30329-4027.
Suggested Citation: [Author names; first three, then et al., if more than six.] [Title]. MMWR 2014;63(No. RR-#):[inclusive page numbers].
Centers for Disease Control and Prevention
Thomas R. Frieden, MD, MPH, Director
Harold W. Jaffe, MD, MA, Associate Director for Science
Joanne Cono, MD, ScM, Acting Director, Office of Science Quality
Chesley L. Richards, MD, MPH, Deputy Director for Public Health Scientific Services
Michael F. Iademarco, MD, MPH, Director, Center for Surveillance, Epidemiology, and Laboratory Services
MMWR Editorial and Production Staff (Serials)
John S. Moran, MD, MPH, Acting Editor-in-Chief Martha F. Boyd, Lead Visual Information Specialist
Christine G. Casey, MD, Editor Maureen A. Leahy, Julia C. Martinroe,
Teresa F. Rutledge, Managing Editor Stephen R. Spriggs, Terraye M. Starr
David C. Johnson, Lead Technical Writer-Editor Visual Information Specialists
Jeffrey D. Sokolow, MA, Project Editor Quang M. Doan, MBA, Phyllis H. King
Information Technology Specialists
MMWR Editorial Board

William L. Roper, MD, MPH, Chapel Hill, NC, Chairman
Matthew L. Boulton, MD, MPH, Ann Arbor, MI Timothy F. Jones, MD, Nashville, TN
Virginia A. Caine, MD, Indianapolis, IN Rima F. Khabbaz, MD, Atlanta, GA
Barbara A. Ellis, PhD, MS, Atlanta, GA Dennis G. Maki, MD, Madison, WI
Jonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA Patricia Quinlisk, MD, MPH, Des Moines, IA
David W. Fleming, MD, Seattle, WA Patrick L. Remington, MD, MPH, Madison, WI
William E. Halperin, MD, DrPH, MPH, Newark, NJ William Schaffner, MD, Nashville, TN
King K. Holmes, MD, PhD, Seattle, WA
Providing Quality Family Planning Services

Recommendations of CDC and the U.S. Office of Population Affairs
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
Summary
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.
This report can assist primary care providers in offering family planning services that will help women, men, and couples achieve
their desired number and spacing of children and increase the likelihood that those children are born healthy. The report provides
recommendations for how to help prevent and achieve pregnancy, emphasizes offering a full range of contraceptive methods for
persons seeking to prevent pregnancy, highlights the special needs of adolescent clients, and encourages the use of the family planning
visit to provide selected preventive health services for women, in accordance with the recommendations for women issued by the
Institute of Medicine and adopted by HHS.
Introduction Family planning services can help address these and other public
health challenges by providing education, counseling, and medical
The United States continues to face challenges to improving services (5). Family planning services include the following:
the reproductive health of the U.S. population. Nearly half (49%) • providing contraception to help women and men plan
of all pregnancies are unintended (1). Although adolescent birth and space births, prevent unintended pregnancies, and
rates declined by more than 61% during 1991–2012, the United reduce the number of abortions;
States has one of the highest adolescent pregnancy rates in the • offering pregnancy testing and counseling;
developed world, with >700,000 adolescents aged 15–19 years • helping clients who want to conceive;
becoming pregnant each year and >300,000 giving birth (2,3). • providing basic infertility services;
Approximately one of eight pregnancies in the United States • providing preconception health services to improve infant
results in a preterm birth, and infant mortality rates remain high and maternal outcomes and improve women’s and men’s
compared with other developed countries (3,4). Moreover, all health; and
of these outcomes affect racial and ethnic minority populations • providing sexually transmitted disease (STD) screening
disproportionately (1–4). and treatment services to prevent tubal infertility and
improve the health of women, men, and infants.
Corresponding preparers: Loretta Gavin, PhD, Division of Reproductive This report provides recommendations developed
Health, National Center for Chronic Disease Prevention and Health
Promotion, CDC. Telephone: 770-488-6284; E-mail: [email protected]; collaboratively by CDC and the Office of Population Affairs
Susan Moskosky, MS, Office of Population Affairs, US Department of (OPA) of the U.S. Department of Health and Human Services
Health and Human Services. Telephone: 240-453-2818; E-mail: (HHS). The recommendations outline how to provide family
[email protected].
planning services by:
MMWR / April 25, 2014 / Vol. 63 / No. 4 1

• defining a core set of family planning services for women defines health-care quality as the extent to which health-care
and men, services improve health outcomes in a manner that is consistent
• describing how to provide contraceptive and other clinical with current professional knowledge (10,13). According to
services, serve adolescents, and perform quality IOM, quality health care has the following attributes:
improvements, and • Safety. These recommendations integrate other CDC
• encouraging the use of the family planning visit to provide recommendations about which contraceptive methods can
selected preventive health services for women, in accordance be provided safely to women with various medical
with the recommendations for women issued by the conditions, and integrate CDC and U.S. Preventive
Institute of Medicine (IOM) and adopted by HHS (6). Services Task Force (USPSTF) recommendations on STD,
The collaboration between CDC and OPA drew on the preconception, and related preventive health services.
strengths of both agencies. CDC has a long-standing history of • Effectiveness. These recommendations support offering
developing evidence-based recommendations for clinical care, a full range of Food and Drug Administration
and OPA’s Title X Family Planning Program (7) has served as (FDA)–approved contraceptive methods as well as
the national leader in direct family planning service delivery counseling that highlights the effectiveness of contraceptive
since the Title X program was established in 1970. methods overall and, in specific patient situations, draws
This report provides recommendations for providing care to attention to the effectiveness of specific clinical preventive
clients of reproductive age who are in need of family planning health services and identifies clinical preventive health
services. These recommendations are intended for all current services for which the potential harms outweigh the
or potential providers of family planning services, including benefits (i.e., USPSTF “D” recommendations).
those funded by the Title X program. • Client-centered approach. These recommendations
encourage taking a client-centered approach by
Current Context of Family 1) highlighting that the client’s primary purpose for
visiting the service site must be respected, 2) noting the
Planning Services importance of confidential services and suggesting ways
Women of reproductive age often report that their family to provide them, 3) encouraging the availability of a broad
planning provider is also their usual source of health care (8). range of contraceptive methods so that clients can make
As the U.S. health-care system evolves in response to increased a selection based on their individual needs and preferences,
efforts to expand health insurance coverage, contain costs, and and 4) reinforcing the need to deliver services in a
emphasize preventive care (9), providers of family planning culturally competent manner so as to meet the needs of
services will face new challenges and opportunities in care all clients, including adolescents, those with limited
delivery. For example, they will have increased opportunities English proficiency, those with disabilities, and those who
to serve new clients and to serve as gateways for their clients to are lesbian, gay, bisexual, transgender, or questioning their
other essential health-care services. In addition, primary care sexual identity (LGBTQ). Organizational policies,
and other providers who provide a range of health-care services governance structures, and individual attitudes and
will be expected to integrate family planning services for all practices all contribute to the cultural competence of a
persons of reproductive age, including those whose primary health-care entity and its staff. Cultural competency within
reason for their health-care visit might not be family planning. a health-care setting refers to attitudes, practices, and
Strengthened, multidirectional care coordination also will be policies that enable professionals to work effectively in
needed to improve health outcomes. For example, this type cross-cultural situations (14–16).
of care coordination will be needed with clients referred to • Timeliness. These recommendations highlight the
specialist care after initial screening at a family planning visit, importance of ensuring that services are provided to clients
as well as with specialists referring clients with family planning in a timely manner.
needs to family planning providers. • Efficiency. These recommendations identify a core set of
services that providers can focus on delivering, as well as
Defining Quality in Family ways to maximize the use of resources.
Planning Service Delivery • Accessibility. These recommendations address how to
remove barriers to contraceptive use, use the family planning
The central premise underpinning these recommendations visit to provide access to a broader range of primary care
is that improving the quality of family planning services will and behavioral health services, use the primary care visit to
lead to improved reproductive health outcomes (10–12). IOM
2 MMWR / April 25, 2014 / Vol. 63 / No. 4

provide access to contraceptive and other family planning CDC and OPA used the input from the subject matter
services, and strengthen links to other sources of care. experts to develop a set of core recommendations and asked
• Equity. These recommendations highlight the need for the Expert Work Group to review them. The members of
providers of family planning services to deliver high- the Expert Work Group were more familiar with the family
quality care to all clients, including adolescents, LGBTQ planning service delivery context than the members of the
persons, racial and ethnic minorities, clients with limited Technical Panel and thus could better comment on the
English proficiency, and persons living with disabilities. feasibility and appropriateness of the recommendations,
• Value. These recommendations highlight services (i.e., as well as the supporting evidence. The Expert Work
contraception and other clinical preventive services) that Group considered the core recommendations by using the
have been shown to be very cost-effective (17–19). 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,
Methods and implementation challenges; and 3) the relative importance
of these consequences, (e.g., the likelihood that implementation
Recommendations Development Process of the recommendation will have a substantial effect on health
The recommendations were developed jointly under the outcomes might be considered more than the logistical
auspices of CDC’s Division of Reproductive Health and challenges of implementing it) (20). In certain cases, when
OPA, in consultation with a wide range of experts and key the evidence from the literature reviews was inconclusive or
stakeholders. More information about the processes used to incomplete, recommendations were made on the basis of expert
conduct systematic reviews, the role of technical experts in opinion. Finally, CDC and OPA staff considered the individual
reviewing the evidence, and the process of using the evidence feedback from Expert Work Group members when finalizing
to develop recommendations is provided (Appendix A). A the core recommendations and writing the recommendations
multistage process was used to develop the recommendations document. A description of how the recommendations link
that drew on established procedures for developing clinical to the evidence is provided together with the rationale for the
guidelines (20,21). First, an Expert Work Group* was formed inclusion of each recommendation in this report (Appendix B).
comprising family planning clinical providers, program The evidence used to prepare these recommendations
administrators, and representatives from relevant federal will appear in background papers that will be published
agencies and professional medical associations to help define separately. Resources that will help providers implement the
the scope of the recommendations. Next, literature about recommendations will be provided through a web-based tool
three priority topics (i.e., counseling and education, serving kit that will be available at http://www.hhs.gov/opa.
adolescents, and quality improvement) was reviewed by using
the USPSTF methodology for conducting systematic reviews Audience for the Recommendations
(22). The results were presented to three technical panels†
The primary audience for this report is all providers or
comprising subject matter experts (one panel for each priority
potential providers of family planning services to clients of
topic) who considered the quality of the evidence and made
reproductive age, including providers working in clinics that
suggestions for what recommendations might be supported on
are dedicated to family planning service delivery, as well as
the basis of the evidence. In a separate process, existing clinical
private and public providers of more comprehensive primary
recommendations on women’s and men’s preventive services
care. Providers of dedicated family planning services might be
were compiled from more than 35 federal and professional
less familiar with the specific recommendations for the delivery
medical associations, and these results were presented to two
of preconception services. Providers of more comprehensive
technical panels of subject matter experts, one that addressed
primary care might be less familiar with the delivery of
women’s clinical services and one that addressed men’s clinical
contraceptive services, pregnancy testing and counseling, and
services. The panels provided individual feedback about
services to help clients achieve pregnancy.
which clinical preventive services should be offered in a family
This report can be used by medical directors to write clinical
planning setting and which clinical recommendations should
protocols that describe how care should be provided. Job aids
receive the highest consideration.
and other resources for use in service sites are being developed
* A list of the members of the Expert Work Group appears on page 52. and will be made available when ready through OPA’s website
† A list of the members of the technical panels appears on pages 52 and 53.
(http://www.hhs.gov/opa).
MMWR / April 25, 2014 / Vol. 63 / No. 4 3

In this report, the term “provider” refers to any staff member BOX 1. Definitions of quality terms used in this report
who is involved in providing family planning services to a
client. This includes physicians, physician assistants, nurse Accessible. The timely use of personal health services
practitioners, nurse-midwives, nursing staff, and health to achieve the best possible health outcomes.*
educators. The term “service site” represents the numerous Client-centered. Care is respectful of, and responsive
settings in which family planning services are delivered, which to, individual client preferences, needs, and values; client
include freestanding service sites, community health centers, values guide all clinical decisions.†
private medical facilities, and hospitals. A list of special terms Effective. Services are based on scientific knowledge and
used in this report is provided (Box 1). provided to all who could benefit and are not provided to
The recommendations are designed to guide general clinical those not likely to benefit.†
practice; however, health-care providers always should consider Efficient. Waste is avoided, including waste of equipment,
the individual clinical circumstances of each person seeking supplies, ideas, and energy.†
family planning services. Similarly, these recommendations Equitable. Care does not vary in quality because of the
might need to be adapted to meet the needs of particular personal characteristics of clients (e.g., sex, race/ethnicity,
populations, such as clients who are HIV-positive or who are geographic location, insurance status, or socioeconomic
substance users. status).†
Evidence-based. The process of integrating science-
based interventions with community preferences to
Organization of the Recommendations
improve the health of populations.§
This report is divided into nine sections. An initial section Health-care quality. The degree to which health-care
provides an overview of steps to assess the needs of a client services for individuals and populations increase the
and decide what family planning services to offer. Subsequent likelihood of desired health outcomes and are consistent
sections describe how to provide each of the following services: with current professional knowledge.†
contraceptive services, pregnancy testing and counseling, helping Process. Whether services are provided correctly and
clients achieve pregnancy, basic infertility services, preconception completely and how clients perceive the care they receive.¶
health services, STD services and related preventive health services. Safe. Avoids injuries to clients from the care that is
A final section on quality improvement describes actions that all intended to help them.†
providers of family planning services should consider to ensure Structure. The characteristics of the settings in which
that services are of high quality. More detailed information about providers deliver health care, including material resources,
selected topics addressed in the recommendations is provided human resources, and organizational structure.¶
(Appendices A–F). Timely. Waits and sometimes harmful delays for both
These recommendations focus on the direct delivery of care those who receive and those who provide care are reduced.†
to individual clients. However, parallel steps might need to be Value. The care provides good return relative to the costs
taken to maintain the systems required to support the provision of involved, such as a return on investment or a reduction in
quality services for all clients (e.g., record-keeping procedures that the per capita cost of health care.*
preserve client confidentiality, procedures that improve efficiency
and reduce clients’ wait time, staff training to ensure that all clients * Source: Institute of Medicine. Future directions for the national healthcare
are treated with respect, and the establishment and maintenance quality and disparities reports. Ulmer C, Bruno M, Burke S, eds.
Washington, DC: The National Academies Press; 2010.
of a strong system of care coordination and referrals). † Source: Institute of Medicine. Crossing the quality chasm: a new health
system for the 21st century. Committee on Quality of Health Care in
Client Care America, ed. Washington, DC: National Academies of Science; 2001.
§ Source: Kohatsu ND, Robinson JG, Torner JC. Evidence-based public
Family planning services are embedded within a broader health: an evolving concept. Am J Prev Med 2004;27:417–21.
framework of preventive health services (Figure 1). In this ¶ Source: Donabedian A. The quality of care. JAMA 1988;260:1743–8.
report, health services are divided into three main categories:

• Family planning services. These include contraceptive and other preconception health services are considered family
services for clients who want to prevent pregnancy and space planning services because they improve women’s and men’s
births, pregnancy testing and counseling, assistance to achieve health and can influence a person’s ability to conceive or to
pregnancy, basic infertility services, STD services (including have a healthy birth outcome.
HIV/AIDS), and other preconception health services (e.g., • Related preventive health services. These include services
screening for obesity, smoking, and mental health). STD/HIV that are considered to be beneficial to reproductive health,
4 MMWR / April 25, 2014 / Vol. 63 / No. 4

FIGURE 1. Family planning and related and other preventive health (i.e., contraceptive services, pregnancy testing and counseling,
services or becoming pregnant). Other aspects of managing pregnancy
(e.g., prenatal and delivery care ) are not addressed in these
recommendations. For clients seeking to prevent or achieve
Family planning services pregnancy, providers should assess whether the client needs
• Contraceptive services other related services and offer them to the client. In the second
• Pregnancy testing and
counseling
type of encounter, the primary reason for a client’s visit to a
• Achieving pregnancy health-care provider is not related to preventing or achieving
• Basic infertility services pregnancy. For example, the client might come in for acute
• Preconception health
care (e.g., a male client coming in for STD symptoms or as
• Sexually transmitted
disease services a contact of a person with an STD), for chronic care, or for
another preventive service. In this situation, providers not only
should address the client’s primary reason for the visit but also
Related preventive assess the client’s need for services related to preventing or
health services
(e.g., screening for breast achieving pregnancy.
and cervical cancer) A clinical pathway of family planning services for women and
men of reproductive age is provided (Figure 2). The following
Other preventive questions can help providers determine what family planning
health services services are most appropriate for a given visit.
(e.g., screening for lipid
disorders)
• What is the client’s reason for the visit? It is essential to
understand the client’s goals for the visit and address those
needs to the extent possible.
• Does the client have another source of primary health
care? Understanding whether a provider is the main source
are closely linked to family planning services, and are of primary care for a client will help identify what
appropriate to deliver in the context of a family planning visit preventive services a provider should offer. If a provider is
but that do not contribute directly to achieving or preventing the client’s main source of primary care, it will be
pregnancy (e.g., breast and cervical cancer screening). important to assess the client’s needs for the other services
• Other preventive health services. These include listed in this report. If the client receives ongoing primary
preventive health services for women that were not care from another provider, the provider should confirm
included above (6), as well as preventive services for men. that the client’s preventive health needs are met while
Screening for lipid disorders, skin cancer, colorectal cancer, avoiding the delivery of duplicative services.
or osteoporosis are examples of this type of service. • What is the client’s reproductive life plan? An assessment
Although important in the context of primary care, these should be made of the client’s reproductive life plan, which
have no direct link to family planning services. outlines personal goals about becoming pregnant (23–25)
Providers of family planning services should be trained and (Box 2).The provider should avoid making assumptions
equipped to offer all family planning and related preventive about the client’s needs based on his or her characteristics,
health services so that they can provide optimal care to clients, such as sexual orientation or disabilities. For clients whose
with referral for specialist care, as needed. Other preventive initial reason for coming to the service site was not related to
health services should be available either on-site or by referral, preventing or achieving pregnancy, asking questions about
but these recommendations do not address this category his or her reproductive life plan might help identify unmet
of services. Information about preventive services that are reproductive health-care needs. Identifying a need for
beyond the scope of this report is available at http://www. contraceptive services might be particularly important given
uspreventiveservicestaskforce.org. the high rate of unintended pregnancy in the United States.
–– If the client does not want a child at this time and is
Determining the Client’s Need for Services sexually active, then offer contraceptive services.
These recommendations apply to two types of encounters –– If the client desires pregnancy testing, then provide
with women and men of reproductive age. In the first type of pregnancy testing and counseling.
encounter, the primary reason for a client’s visit to a health- –– If the client wants to have a child now, then provide
care provider is related to preventing or achieving pregnancy, services to help the client achieve pregnancy.
MMWR / April 25, 2014 / Vol. 63 / No. 4 5

FIGURE 2. Clinical pathway of family planning services for women and men of reproductive age
Determine the need for services among

female and male clients of reproductive age
• Assess reason for visit
• Assess source of primary care
• Assess reproductive life plan
Reason for visit is related to Initial reason for visit is not

preventing or achieving related to preventing or
pregnancy achieving pregnancy
• Acute care
• Chronic care management
• Preventive services
Contraceptive Pregnancy Achieving Basic
services testing and pregnancy infertility
counseling services
Assess need for services related

If needed, to preventing or achieving
provide pregnancy
services
Clients also should be Sexually If services are not needed at this

Preconception
provided these transmitted visit, reassess at subsequent visits
health
services, per disease services
clinical recommendations services
Related
Clients also should be provided
preventive
or referred for these services,
health
per clinical recommendations
services
–– If the client wants to have a child and is experiencing at every visit. Many clients requesting contraceptive services
difficulty conceiving, then provide basic infertility services. also might meet the criteria for being at risk of one or more
• Does the client need preconception health services? STDs. Screening for chlamydia and gonorrhea is especially
Preconception health services (such as screening for important in a family planning context because these STDs
obesity, smoking, and mental health) are a subset of all contribute to tubal infertility if left untreated. STD services
preventive services for women and men. Preconception are also necessary to maximize preconception health. The
health care is intended to promote the health of women federal recommendations cited in this report should be
and men of reproductive age before conception, with the followed when determining which STD services a client
goal of improving pregnancy-related outcomes (24). might need. Aspects of managing symptomatic STDs are
Preconception health services are also important because not addressed in these recommendations.
they improve the health of women and men, even if they • What other related preventive health services does the
choose not to become pregnant. The federal and client need? Whether the client needs related preventive
professional medical recommendations cited in this report health services, such as breast and cervical cancer screening
should be followed when determining which preconception for female clients, should be assessed. The federal and
health services a client might need. professional medical recommendations cited in this report
• Does the client need STD services? The need for STD should be followed when determining which related
services, including HIV/AIDS testing, should be considered preventive health services a client might need.
6 MMWR / April 25, 2014 / Vol. 63 / No. 4

BOX 2. Recommended questions to ask when assessing a client’s

reproductive life plan
Contraceptive Services
Providers should offer contraceptive services to clients who
Providers should discuss a reproductive life plan with wish to delay or prevent pregnancy. Contraceptive services
clients receiving contraceptive, pregnancy testing and should include consideration of a full range of FDA-approved
counseling, basic infertility, sexually transmitted disease, contraceptive methods, a brief assessment to identify the
and preconception health services in accordance with contraceptive methods that are safe for the client, contraceptive
CDC’s recommendation that all persons capable of having counseling to help a client choose a method of contraception
a child should have a reproductive life plan.* and use it correctly and consistently, and provision of one or
Providers should assess the client’s reproductive life plan more selected contraceptive method(s), preferably on site, but
by asking the client questions such as: by referral if necessary. Contraceptive counseling is defined as
• Do you have any children now? a process that enables clients to make and follow through on
• Do you want to have (more) children? decisions about their contraceptive use. Education is an integral
• How many (more) children would you like to have component of the contraceptive counseling process that helps
and when? clients to make informed decisions and obtain the information
they need to use contraceptive methods correctly.
* Source: CDC. Recommendations to improve preconception health and Key steps in providing contraceptive services, including
health care—United States: a report of the CDC/ATSDR Preconception
Care Work Group and the Select Panel on Preconception Care. MMWR
contraceptive counseling and education, have been outlined
2006;55(No. RR-6). (Box 3). These key steps are in accordance with the five principles
of quality counseling (Appendix C). To help a client who is
The individual client’s needs should be considered when initiating or switching to a new method of contraception,
determining what services to offer at a given visit. It might not providers should follow these steps. These steps most likely will
be feasible to deliver all the needed services in a single visit, and be implemented iteratively when working with a client and
they might need to be delivered over the course of several visits. should help clients adopt, change, or maintain contraceptive use.
Providers should tailor services to meet the specific needs of Step 1. Establish and maintain rapport with the client.
the population they serve. For example, clients who are trying Providers should strive to establish and maintain rapport.
to achieve pregnancy and those at high risk of unintended Strategies to achieve these goals include the following:
pregnancy should be given higher priority for preconception • using open-ended questions;
health services. In some cases, the provider will deliver the • demonstrating expertise, trustworthiness, and accessibility;
initial screening service but then refer to another provider for • ensuring privacy and confidentiality;
further diagnosis or follow-up care. • explaining how personal information will be used;
The delivery of preconception, STD, and related preventive • encouraging the client to ask questions and share
health services should not become a barrier to a client’s ability information;
to receive services related to preventing or achieving pregnancy. • listening to and observing the client; and
For these clients, receiving services related to preventing or • being encouraging and demonstrating empathy and
achieving pregnancy is the priority; if other family planning acceptance.
services cannot be delivered at the initial visit, then follow-up Step 2. Obtain clinical and social information from
visits should be scheduled. the client. Providers should ask clients about their medical
In addition, professional recommendations for how to history to identify methods that are safe. In addition, to learn
address the needs of diverse clients, such as LGBTQ persons more about factors that might influence a client’s choice of a
(26–32) or persons with disabilities (33), should be consulted contraceptive method, providers should confirm the client’s
and integrated into procedures, as appropriate. For example, pregnancy intentions or reproductive life plan, ask about the
as noted before, providers should avoid making assumptions client’s contraceptive experiences and preferences, and conduct
about a client’s gender identity, sexual orientation, race, a sexual health assessment. When available, standardized tools
or ethnicity; all requests for services should be treated should be used.
without regard to these characteristics. Similarly, services for • Medical history. A medical history should be taken to
adolescents should be provided in a “youth-friendly” manner, ensure that methods of contraception being considered
which means that they are accessible, equitable, acceptable, by a client are safe for that particular client. For a female
appropriate, comprehensive, effective, and efficient for youth, client, the medical history should include menstrual
as recommended by the World Health Organization (34). history (including last menstrual period, menstrual
frequency, length and amount of bleeding, and other
MMWR / April 25, 2014 / Vol. 63 / No. 4 7

BOX 3. Steps in providing contraceptive services, including contraception?”; “Did you use contraception at last sex?”;
contraceptive counseling* and education “What difficulties did you experience with prior methods
if any (e.g., side effects or noncompliance)?”; “Do you
• Establish and maintain rapport with the client. have a specific method in mind?”; and “Have you discussed
• Obtain clinical and social information from the client. method options with your partner, and does your partner
• Work with the client interactively to select the most have any preferences for which method you use?” Male
effective and appropriate contraceptive method. clients should be asked if they are interested in vasectomy.
• Conduct a physical assessment related to • Sexual health assessment. A sexual history and risk
contraceptive use, only when warranted. assessment that considers the client’s sexual practices,
• Provide the contraceptive method along with partners, past STD history, and steps taken to prevent
instructions about correct and consistent use, help the STDs (36) is recommended to help the client select the
client develop a plan for using the selected method most appropriate method(s) of contraception. Correct and
and for follow up, and confirm client understanding. consistent condom use is recommended for those at risk
* Key principles of providing quality counseling including education have
for STDs. CDC recommendations for how to conduct a
been outlined (Appendix C). sexual health assessment have been summarized (Box 4).
Step 3. Work with the client interactively to select the most
effective and appropriate contraceptive method. Providers
patterns of uterine/vaginal bleeding), gynecologic and
should work with the client interactively to select an effective
obstetrical history, contraceptive use, allergies, recent
and appropriate contraceptive method. Specifically, providers
intercourse, recent delivery, miscarriage, or termination,
should educate the client about contraceptive methods that
and any relevant infectious or chronic health condition
the client can safely use, and help the client consider potential
and other characteristics and exposures (e.g., age,
barriers to using the method(s) under consideration. Use of
postpartum, and breastfeeding) that might affect the
decision aids (e.g., computerized programs that help a client
client’s medical eligibility criteria for contraceptive
to identify a range of methods that might be appropriate for
methods (35). Clients considering combined hormonal
the client based on her physical characteristics such as health
contraception should be asked about smoking tobacco, in
conditions or preferences about side effects) before or while
accordance with CDC guidelines on contraceptive use
waiting for the appointment can facilitate and maximize the
(35). Additional details about the methods of contraception
utility of the time spent on this step.
that are safe to use for female clients with specific medical
Providers should inform clients about all contraceptive
conditions and characteristics (e.g., hypertension) are
methods that can be used safely. Before the health-care visit,
addressed in previously published guidelines (35). For a
clients might have only limited information about all or
male client, a medical history should include use of
specific methods of contraception (37). A broad range of
condoms, known allergies to condoms, partner use of
methods, including long-acting reversible contraception (i.e.,
contraception, recent intercourse, whether his partner is
intrauterine devices [IUDs] and implants), should be discussed
currently pregnant or has had a child, miscarriage, or
with all women and adolescents, if medically appropriate.
termination, and the presence of any infectious or chronic
Providers are encouraged to present information on potential
health condition. However, the taking of a medical history
reversible methods of contraception by using a tiered approach
should not be a barrier to making condoms available in
(i.e., presenting information on the most effective methods first,
the clinical setting (i.e., a formal visit should not be a
before presenting information on less effective methods) (38,39).
prerequisite for a client to obtain condoms).
This information should include an explanation that long-
• Pregnancy intention or reproductive life plan. Each
acting reversible contraceptive methods are safe and effective for
client should be encouraged to clarify decisions about her
most women, including those who have never given birth and
or his reproductive life plan (i.e., whether the client wants
adolescents (35). Information should be tailored and presented
to have any or more children and, if so, the desired timing
to ensure a client-centered approach. It is not appropriate to omit
and spacing of those children) (24).
presenting information on a method solely because the method
• Contraceptive experiences and preferences. Method-
is not available at the service site. If not all methods are available
specific experiences and preferences should be assessed by
at the service site, it is important to have strong referral links in
asking questions such as, “What method(s) are you
place to other providers to maximize opportunities for clients
currently using, if any?”; “What methods have you used
to obtain their preferred method that is medically appropriate.
in the past?”; “Have you previously used emergency
8 MMWR / April 25, 2014 / Vol. 63 / No. 4

BOX 4. Steps in conducting a sexual health assessment* a method. For example, receiving a contraceptive injection
every 3 months might not be acceptable to a woman who
• Practices: Explore the types of sexual activity in which fears injections. Similarly, oral contraceptives might not
the patient engages (e.g., vaginal, anal, or oral sex). be acceptable to a woman who is concerned that she might
• Pregnancy prevention: Discuss current and future not be able to remember to take a pill every day.
contraceptive options. Ask about current and previous • Noncontraceptive benefits. Many contraceptives have
use of methods, use of contraception at last sex, noncontraceptive benefits, in addition to preventing
difficulties with contraception, and whether the client pregnancy, such as reducing heavy menstrual bleeding.
has a particular method in mind. Although the noncontraceptive benefits are not generally
• Partners: Ask questions to determine the number, gender the major determinant for selecting a method, awareness
(men, women, or both), and concurrency of the patient’s of these benefits can help clients decide between two or
sex partners (if partner had sex with another partner while more suitable methods and might enhance the client’s
still in a sexual relationship with the patient). It might be motivation to use the method correctly and consistently.
necessary to define the term “partner” to the patient or use • Side effects. Providers should inform the client about risks
other, relevant terminology. and side effects of the method(s) under consideration, help
• Protection from sexually transmitted diseases the client understand that certain side effects of contraceptive
(STDs): Ask about condom use, with whom they do methods might disappear over time, and encourage the
or do not use condoms, and situations that make it client to weigh the experience of coping with side effects
harder or easier to use condoms. Topics such as against the experience and consequences of an unintended
monogamy and abstinence also can be discussed. pregnancy. The provider should be prepared to discuss and
• Past STD history: Ask about any history of STDs, correct misperceptions about side effects. Clients also should
including whether their partners have ever had an be informed about warning signs for rare, but serious,
STD. Explain that the likelihood of an STD is higher adverse events with specific contraceptive methods, such as
with a past history of an STD. stroke and venous thromboembolism with use of combined
hormonal methods.
* Source: CDC. Sexually transmitted diseases treatment guidelines, 2010.
MMWR 2010;59(No. RR-12).
• Protection from STDs, including HIV. Clients should
be informed that contraceptive methods other than
condoms offer no protection against STDs, including
For clients who have completed childbearing or do not plan HIV. Condoms, when used correctly and consistently,
to have children, permanent sterilization (female or male) is an help reduce the risk of STDs, including HIV, and provide
option that may be discussed. Both female and male sterilization protection against pregnancy. Dual protection (i.e.,
are safe, are highly effective, and can be performed in an office protection from both pregnancy and STDs) is important
or outpatient surgery setting (40,41). Women and men should for clients at risk of contracting an STD, such as those
be counseled that these procedures are not intended to be with multiple or potentially infected partner(s). Dual
reversible and that other highly effective, reversible methods of protection can be achieved through correct and consistent
contraception (e.g., implants or IUDs) might be an alternative use of condoms with every act of sexual intercourse, or
if they are unsure about future childbearing. Clients interested correct and consistent use of a condom to prevent infection
in sterilization should be referred to an appropriate source of plus another form of contraception to prevent pregnancy.
care if the provider does not perform the procedure. (For more information about preventing and treating
When educating clients about contraceptive methods that STDs, see STD Services.)
the clients can use safely, providers should ensure that clients When educating clients about the range of contraceptive
understand the following: methods, providers should ensure that clients have information
• Method effectiveness. A contraceptive method’s rate of that is medically accurate, balanced, and provided in a
typical effectiveness, or the percentage of women nonjudgmental manner. To assist clients in making informed
experiencing an unintended pregnancy during the first decisions, providers should educate clients in a manner that
year of typical use, is an important consideration (Figure 3; can be readily understood and retained. The content, format,
Appendix D) (38,42). method, and medium for delivering education should be
• Correct use of the method. The mode of administration evidence-based (see Appendix E).
and understanding how to use the method correctly might When working with male clients, when appropriate, providers
be important considerations for the client when choosing should discuss information about female-controlled methods
MMWR / April 25, 2014 / Vol. 63 / No. 4 9

FIGURE 3. The typical effectiveness of Food and Drug Administration–approved contraceptive methods
(including emergency contraception) encourage discussion of contraception (47). Providers should help the client
contraception with partners, and provide information about how consider the advantages and disadvantages of the
partners can access contraceptive services. Male clients should method(s) being considered, the client’s feelings about
also be reminded that condoms should be used correctly and using the method(s), how her or his partner is likely to
consistently to reduce risk of STDs, including HIV. respond, the client’s peers’ perceptions of the method(s),
When working with any client, encourage partner and the client’s confidence in being able to use the method
communication about contraception, as well as understanding correctly and consistently (e.g., using a condom during
partner barriers (e.g., misperceptions about side effects) and every act of intercourse or remembering to take a pill every
facilitators (e.g., general support) of contraceptive use (43–46). day) (37).
The provider should help the client consider potential • Intimate partner violence and sexual violence. Current
barriers to using the method(s) under consideration. This and past intimate partner sexual or domestic violence
includes consideration of the following factors: might impede the correct and consistent use of
• Social-behavioral factors. Social-behavioral factors might contraception, and might be a consideration when
influence the likelihood of correct and consistent use of choosing a method (47–49). For example, an IUD might
10 MMWR / April 25, 2014 / Vol. 63 / No. 4

be preferred because it does not require the partner’s • Unnecessary medical procedures and tests might create
participation. The medical history might provide logistical, emotional, or economic barriers to contraceptive
information on signs of current or past violence and, if access for some women, particularly adolescents and low-
not, providers should ask clients about relationship issues income women, who have high rates of unintended
that might be potential barriers to contraceptive use. In pregnancies (1,51,52). For both adolescent and adult
addition, clients experiencing intimate partner violence female clients, the following examinations and tests are
or sexual violence should be referred for appropriate care. not needed routinely to provide contraception safely to a
• Mental health and substance use behaviors. Mental health healthy client (although they might be needed to address
(e.g., depression, anxiety disorders, and other mental other non-contraceptive health needs) (42):
disorders) and substance use behaviors (e.g., alcohol use, –– pelvic examinations, unless inserting an intrauterine
prescription abuse, and illicit drug use) might affect a client’s device (IUD) or fitting a diaphragm;
ability to correctly and consistently use contraception –– cervical cytology or other cancer screening, including
(47,50). The medical history might provide information clinical breast exam;
about the signs of such conditions or behaviors, and if not, –– human immunodeficiency virus (HIV) screening; and
providers should ask clients about substance use behaviors –– laboratory tests for lipid, glucose, liver enzyme, and
or mental health disorders, such as depression or anxiety, hemoglobin levels or thrombogenic mutations.
that might interfere with the motivation or ability to follow For male clients, no physical examination needs to be
through with contraceptive use. If needed, clients with performed before distributing condoms.
mental health disorders or risky substance use behaviors Step 5. Provide the contraceptive method along with
should be referred for appropriate care. instructions about correct and consistent use, help the
Step 4. Conduct a physical assessment related to client develop a plan for using the selected method and for
contraceptive use, when warranted. Most women will need follow-up, and confirm client understanding.
no or few examinations or laboratory tests before starting a • A broad range of FDA-approved contraceptive methods
method of contraception. Guidance on necessary examinations should be available onsite. Referrals for methods not
and tests related to initiation of contraception is available (42). available onsite should be provided for clients who indicate
A list of assessments that need to be conducted when providing they prefer those methods. When providing contraception,
reversible contraceptive services to a female client seeking to providers should instruct the client about correct and
initiate or switch to a new method of reversible contraception is consistent use and employ the following strategies to
provided (Table 1) (42). Clinical evaluation of a client electing facilitate a client’s use of contraception:
permanent sterilization should be guided by the clinician who –– Provide onsite dispensing;
performs the procedure. Recommendations for contraceptive –– Begin contraception at the time of the visit rather than
use are available (42). Key points include the following: waiting for next menses (also known as “quick start”) if
• Blood pressure should be taken before initiating the use the provider can reasonably be certain that the client is
of combined hormonal contraception. not pregnant (42). A provider can be reasonably certain
• Providers should assess the current pregnancy status of that a woman is not pregnant if she has no symptoms or
clients receiving contraception (42), which provides signs of pregnancy and meets any one of the following
guidance on how to be reasonably certain that a woman criteria (42,53):
is not pregnant at the time of contraception initiation. In ˏˏ is ≤7 days after the start of normal menses,
most cases, a detailed history provides the most accurate ˏˏ has not had sexual intercourse since the start of last
assessment of pregnancy risk in a woman about to start normal menses,
using a contraceptive method. Routine pregnancy testing ˏˏ has been using a reliable method of contraception
for every woman is not necessary. correctly and consistently,
• Weight measurement is not needed to determine medical ˏˏ is ≤7 days after spontaneous or induced abortion,
eligibility for any method of contraception because all ˏˏ is within 4 weeks postpartum,
methods generally can be used among obese women. ˏˏ is fully or nearly fully breastfeeding (exclusively
However, measuring weight and calculating BMI at baseline breastfeeding or the vast majority [≥85%] of feeds are
might be helpful for monitoring any changes and counseling breastfeeds), amenorrheic, and <6 months postpartum;
women who might be concerned about weight change –– Provide or prescribe multiple cycles (ideally a full year’s
perceived to be associated with their contraceptive method. supply) of oral contraceptive pills, the patch, or the ring
MMWR / April 25, 2014 / Vol. 63 / No. 4 11

TABLE 1. Assessments to conduct when a female client is initiating a new method of reversible contraception
Combined Diaphragm or
Cu-IUD and hormonal Progestin- cervical
LNG-IUD Implant Injectable contraception only pills Condom cap Spermicide
Examination
Blood pressure C C C A* C C C C
Weight (BMI) (weight [kg]/height [m]2) —† —† —† —† —† C C C
Clinical breast examination C C C C C C C C
Bimanual examination and cervical A C C C C C A§ C
inspection
Laboratory test
Glucose C C C C C C C C
Lipids C C C C C C C C
Liver enzymes C C C C C C C C
Hemoglobin C C C C C C C C
Thrombogenic mutations C C C C C C C C
Cervical cytology (Papanicolaou smear) C C C C C C C C
STD screening with laboratory tests —¶ C C C C C C C
HIV screening with laboratory tests C C C C C C C C
Source: CDC. U.S. selected practice recommendations for contraceptive use 2013. MMWR 2013;62(No. RR-5).
Abbreviations: A = Class A: essential and mandatory in all circumstances for safe and effective use of the contraceptive method; B = Class B: contributes substantially
to safe and effective use, but implementation might be considered within the public health and/or service context (the risk of not performing an examination or test
should be balanced against the benefits of making the contraceptive method available); C = Class C: does not contribute substantially to safe and effective use of the
contraceptive method; Cu-IUD = copper-containing intrauterine device; LNG-IUD = levonorgestrel releasing intrauterine device.
* In cases in which access to health care might be limited, the blood pressure measurement can be obtained by the woman in a nonclinical setting (e.g., pharmacy
or fire station) and self-reported to the provider.
† Weight (BMI) measurement is not needed to determine medical eligibility for any methods of contraception because all methods can be used (U.S. Medical Eligibility
Criteria 1) or generally can be used (U.S. Medical Eligibility Criteria 2) among obese women (Source: CDC. U.S. medical eligibility criteria for contraceptive use 2010.
MMWR 2010;59[No. RR-4]). However, measuring weight and calculating BMI at baseline might be helpful for monitoring any changes and counseling women who
might be concerned about weight change perceived to be associated with their contraceptive method.
§ A bimanual examination (not cervical inspection) is needed for diaphragm fitting.
¶ Most women do not require additional STD screening at the time of IUD insertion, if they have already been screened according to CDC’s STD treatment guidelines
(Sources: CDC. STD treatment guidelines. Atlanta, GA: US Department of Health and Human Services, CDC; 2013. Available at http://www.cdc.gov/std/treatment.
CDC. Sexually transmitted diseases treatment guidelines, 2010. MMWR. 2010;59[No. RR-12]). If a woman has not been screened according to guidelines, screening
can be performed at the time of IUD insertion and insertion should not be delayed. Women with purulent cervicitis or current chlamydial infection or gonorrhea
should not undergo IUD insertion (U.S. Medical Eligibility Criteria 4). Women who have a very high individual likelihood of STD exposure (e.g., those with a currently
infected partner) generally should not undergo IUD insertion (U.S. Medical Eligibility Criteria 3) (Source: CDC. U.S. medical eligibility criteria for contraceptive use
2010. MMWR 2010;59[No. RR-4]). For these women, IUD insertion should be delayed until appropriate testing and treatment occurs.
to minimize the number of times a client has to return to messages or cell phone alarms). Providers also may inform
the service site; clients about the availability of emergency contraceptive pills
–– Make condoms easily and inexpensively available; and and may provide clients an advance supply of emergency
–– If a client chooses a method that is not available on-site contraceptive pills on-site or by prescription, if requested.
or the same day, provide the client another method to Side effects (e.g., irregular vaginal bleeding) are a primary
use until she or he can start the chosen method. reason for method discontinuation (54), so providers
• Help the client develop a plan for using the selected should discuss ways the client might deal with potential side
method. Using a method incorrectly or inconsistently and effects to increase satisfaction with the method and improve
having gaps in contraceptive protection because of method continuation (42).
switching both increase the likelihood of an unintended • Develop a plan for follow-up. Providers should discuss an
pregnancy (37). After the method has been provided, or appropriate follow-up plan with the client to meet their
a plan put into place to obtain the chosen method, individual needs, considering the client’s risk for
providers should help the client develop an action plan discontinuation. Follow-up provides an opportunity to
for using the selected method. inquire about any initial difficulties the client might be
Providers should encourage clients to anticipate reasons experiencing, and might reinforce the perceived accessibility
why they might not use their chosen method(s) correctly or of the provider and increase rapport. Alternative modes
consistently, and help them develop strategies to deal with of follow-up other than visits to the service site, such as
these possibilities. For example, for a client selecting oral telephone, e-mail, or text messaging, should be considered
contraceptive pills who might forget to take a pill, the provider (assuming confidentiality can be assured), as needed.
can work with the client to identify ways to routinize daily As noted previously, if a client chooses a method that
pill taking (e.g., use of reminder systems such as daily text is not available on-site or during the visit, the provider
12 MMWR / April 25, 2014 / Vol. 63 / No. 4

should schedule a follow-up visit with the client or provide Providers of family planning services should offer confidential
a referral for her or him to receive the method. The client services to adolescents and observe all relevant state laws and
should be provided another method to use until she or he any legal obligations, such as notification or reporting of child
can start the chosen method. abuse, child molestation, sexual abuse, rape, or incest, as well
• Confirm the client’s understanding. Providers should assess as human trafficking (58,59). Confidentiality is critical for
whether the client understands the information that was adolescents and can greatly influence their willingness to access
presented. The client’s understanding of the most and use services (60–67). As a result, multiple professional
important information about her or his chosen medical associations have emphasized the importance of
contraceptive method should be documented in the providing confidential services to adolescents (68–70).
medical record (e.g., by a checkbox or written statement). Providers should encourage and promote communication
The teach-back method may be used to confirm the client’s between the adolescent and his or her parent(s) or guardian(s)
understanding by asking the client to repeat back messages about sexual and reproductive health (71–86). Adolescents
about risks and benefits and appropriate method use and who come to the service site alone should be encouraged to
follow-up. If providers assess the client’s understanding, then talk to their parents or guardians. Educational materials and
the check box or written statement can be used in place of a programs can be provided to parents or guardians that help
written method-specific informed consent form. Topics that them talk about sex and share their values with their child
providers may consider having the client repeat back include (72,87). When both parent or guardian and child have agreed,
the following: typical method effectiveness; how to use the joint discussions can address family values and expectations
method correctly; protection from STDs; warning signs about dating, relationships, and sexual behavior.
for rare, but serious, adverse events and what to do if they In a given year, approximately 20% of adolescent births
experience a warning sign; and when to return for follow-up. represent repeat births (88), so in addition to providing
postpartum contraception, providers should refer pregnant
Provide Counseling for Returning Clients
and parenting adolescents to home visiting and other programs
When serving contraceptive clients who return for ongoing that have been demonstrated to provide needed support and
care related to contraception, providers should ask if the reduce rates of repeat teen pregnancy (89–94).
client has any concerns with the method and assess its use. Services for adolescents should be provided in a “youth-
The provider should assess any changes in the client’s medical friendly” manner, which means that they are accessible,
history, including changes in risk factors and medications that equitable, acceptable, appropriate, comprehensive, effective,
might affect safe use of the contraceptive method. If the client and efficient for youth as recommended by the World Health
is using the method correctly and consistently and there are no Organization (34).
concerns about continued use, an appropriate follow-up plan
should be discussed and more contraceptive supplies given
(42). If the client or provider has concerns about the client’s Pregnancy Testing and Counseling
correct or consistent use of the method, the provider should
Providers of family planning services should offer pregnancy
ask if the client would be interested in considering a different
testing and counseling services as part of core family planning
method of contraception. If the client is interested, the steps
services, in accordance with recommendations of major
described above should be followed.
professional medical organizations, such as the American
Counseling Adolescent Clients College of Obstetricians and Gynecologists (ACOG) and the
Providers should give comprehensive information to American Academy of Pediatrics (AAP) (95–97).
adolescent clients about how to prevent pregnancy (55–57). Pregnancy testing is a common reason for a client to visit a
This information should clarify that avoiding sex (i.e., provider of family planning services. Approximately 65% of
abstinence) is an effective way to prevent pregnancy and STDs. pregnancies result in live births, 18% in induced abortion,
If the adolescent indicates that she or he will be sexually active, and 17% spontaneous fetal loss (98). Among live births, only
providers should give information about contraception and 1% of infants are placed for adoption within their first month
help her or him to choose a method that best meets her or his of life (99).
individual needs, including the use of condoms to reduce the The visit should include a discussion about her reproductive
risk of STDs. Long-acting reversible contraception is a safe life plan and a medical history that includes asking about
and effective option for many adolescents, including those any coexisting conditions (e.g., chronic medical illnesses,
who have not been pregnant or given birth (35). physical disability, psychiatric illness) (95,96). In most cases,
MMWR / April 25, 2014 / Vol. 63 / No. 4 13

a qualitative urine pregnancy test will be sufficient; however, Negative Pregnancy Test
in certain cases, the provider may consider performing a
Women who are not pregnant and who do not want to
quantitative serum pregnancy test, if exact hCG levels would
become pregnant at this time should be offered contraceptive
be helpful for diagnosis and management. The test results
services, as described previously. The contraceptive counseling
should be presented to the client, followed by a discussion of
session should explore why the client thought that she was
options and appropriate referrals.
pregnant and sought pregnancy testing services, and whether
Options counseling should be provided in accordance with
she has difficulties using her current method of contraception.
recommendations from professional medical associations, such as
A negative pregnancy test also provides an opportunity to discuss
ACOG and AAP (95–97). A female client might wish to include
the value of making a reproductive life plan. Ideally, these services
her partner in the discussion; however, if a client chooses not to
will be offered in the same visit as the pregnancy test because
involve her partner, confidentiality must be assured.
clients might not return at a later time for contraceptive services.
Women who are not pregnant and who are trying to become
Positive Pregnancy Test pregnant should be offered services to help achieve pregnancy or
If the pregnancy test is positive, the clinical visit should include basic infertility services, as appropriate (see “Clients Who Want
an estimation of gestational age so that appropriate counseling to Become Pregnant” and “Basic Infertility Services”). They also
can be provided. If a woman is uncertain about the date of her should be offered preconception health and STD services (see
last normal menstrual period, a pelvic examination might be “Preconception Health Services” and “STD services”).
needed to help assess gestational age. In addition, clients should
receive information about the normal signs and symptoms of
early pregnancy, and should be instructed to report any concerns Clients Who Want to
to a provider for further evaluation. If ectopic pregnancy or Become Pregnant
other pregnancy abnormalities or problems are suspected, the
Providers should advise clients who wish to become pregnant
provider should either manage the condition or refer the client
in accordance with the recommendations of professional
for immediate diagnosis and management.
medical organizations, such as the American Society for
Referral to appropriate providers of follow-up care should
Reproductive Medicine (ASRM) (100).
be made at the request of the client, as needed. Every effort
Providers should ask the client (or couple) how long she or
should be made to expedite and follow through on all referrals.
they have been trying to get pregnant and when she or they
For example, providers might provide a resource listing or
hope to become pregnant. If the client’s situation does not
directory of providers to help the client identify options for
meet one of the standard definitions of infertility (see “Basic
care. Depending upon a client’s needs, the provider may make
Infertility Services”), then she or he may be counseled about
an appointment for the client, or call the referral site to let them
how to maximize fertility. Key points are as follows:
know the client was referred. Providers also should assess the
• The client should be educated about peak days and signs
client’s social support and refer her to appropriate counseling
of fertility, including the 6-day interval ending on the day
or other supportive services, as needed.
of ovulation that is characterized by slippery, stretchy
For clients who are considering or choose to continue the
cervical mucus and other possible signs of ovulation.
pregnancy, initial prenatal counseling should be provided
• Women with regular menstrual cycles should be advised
in accordance with the recommendations of professional
that vaginal intercourse every 1–2 days beginning soon
medical associations, such as ACOG (97). The client should
after the menstrual period ends can increase the likelihood
be informed that some medications might be contraindicated
of becoming pregnant.
in pregnancy, and any current medications taken during
• Methods or devices designed to determine or predict the time
pregnancy need to be reviewed by a prenatal care provider
of ovulation (e.g., over-the-counter ovulation kits, digital
(e.g., an obstetrician or midwife). In addition, the client should
telephone applications, or cycle beads) should be discussed.
be encouraged to take a daily prenatal vitamin that includes
• It should be noted that fertility rates are lower among
folic acid; to avoid smoking, alcohol, and other drugs; and
women who are very thin or obese, and those who consume
not to eat fish that might have high levels of mercury (97). If
high levels of caffeine (e.g., more than five cups per day).
there might be delays in obtaining prenantal care, the client
• Smoking, consuming alcohol, using recreational drugs,
should be provided or referred for any needed STD screening
and using most commercially available vaginal lubricants
(including HIV) and vaccinations (36).
should be discouraged as these might reduce fertility.
14 MMWR / April 25, 2014 / Vol. 63 / No. 4

Basic Infertility Services The physical examination should include: height, weight, and
body mass index (BMI) calculation; thyroid examination to
Providers should offer basic infertility care as part of identify any enlargement, nodule, or tenderness; clinical breast
core family planning services in accordance with the examination; and assessment for any signs of androgen excess.
recommendations of professional medical organizations, such A pelvic examination should assess for: pelvic or abdominal
as ACOG, ASRM, and the American Urological Association tenderness, organ enlargement or mass; vaginal or cervical
(AUA) (96,101,102). abnormality, secretions, or discharge; uterine size, shape, position,
Infertility commonly is defined as the failure of a couple and mobility; adnexal mass or tenderness; and cul-de-sac mass,
to achieve pregnancy after 12 months or longer of regular tenderness, or nodularity. If needed, clients should be referred
unprotected intercourse (101). Earlier assessment (such as for further diagnosis and treatment (e.g., serum progesterone
6 months of regular unprotected intercourse) is justified levels, follicle-stimulating hormone/luteinizing hormone levels,
for women aged >35 years, those with a history of oligo- thyroid function tests, prolactin levels, endometrial biopsy,
amenorrhea (infrequent menstruation), those with known or transvaginal ultrasound, hysterosalpingography, laparoscopy,
suspected uterine or tubal disease or endometriosis, or those and clomiphene citrate).
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 Basic Infertility Care for Men
if risk factors of male infertility are known to be present or Infertility services should be provided for the male partner
if there are questions regarding the male partner’s fertility of an infertile couple in accordance with recommendations
potential (102). Infertility visits to a family planning provider developed by professional medical associations such as AUA
are focused on determining potential causes of the inability to (102). Providers should discuss the client’s reproductive life
achieve pregnancy and making any needed referrals to specialist plan, take a medical history, and conduct a sexual health
care (101,102). ASRM recommends that evaluation of both assessment. AUA recommends that the medical history include
partners should begin at the same time (101). a reproductive history (102). The medical history should
include systemic medical illnesses (e.g., diabetes mellitus),
Basic Infertility Care for Women prior surgeries and past infections; medications (prescription
and nonprescription) and allergies; and lifestyle exposures. The
The clinical visit should focus on understanding the client’s reproductive history should include methods of contraception,
reproductive life plan (24) and her difficulty in achieving coital frequency and timing; duration of infertility and prior
pregnancy through a medical history, sexual health assessment fertility; sexual history; and gonadal toxin exposure, including
and physical exam, in accordance with recommendations heat. Patients also should be asked about their female partners’
developed by professional medical associations such as history of pelvic inflammatory disease, their partners’ histories
ASRM (101) and ACOG (96). The medical history should of STDs, and problems with sexual dysfunction.
include past surgery, including indications and outcome(s), In addition, a physical examination should be conducted with
previous hospitalizations, serious illnesses or injuries, medical particular focus given to 1) examination of the penis, including
conditions associated with reproductive failure (e.g., thyroid the location of the urethral meatus; 2) palpation of the testes
disorders, hirsutism, or other endocrine disorders), and and measurement of their size; 3) presence and consistency of
childhood disorders; results of cervical cancer screening and both the vas deferens and epididymis; 4) presence of a varicocele;
any follow-up treatment; current medication use and allergies; 5) secondary sex characteristics; and 6) a digital rectal exam
and family history of reproductive failure. In addition, a (102). Male clients concerned about their fertility should have
reproductive history should include how long the client has a semen analysis. If this test is abnormal, they should be referred
been trying to achieve pregnancy; coital frequency and timing, for further diagnosis (i.e., second semen analysis, endocrine
level of fertility awareness, and results of any previous evaluation evaluation, post-ejaculate urinalysis, or others deemed necessary)
and treatment; gravidity, parity, pregnancy outcome(s), and and treatment. The semen analysis is the first and most simple
associated complications; age at menarche, cycle length and screen for male fertility.
characteristics, and onset/severity of dysmenorrhea; and
sexual history, including pelvic inflammatory disease, history
of STDs, or exposure to STDs. A review of systems should Infertility Counseling
emphasize symptoms of thyroid disease, pelvic or abdominal Counseling provided during the clinical visit should be
pain, dyspareunia, galactorrhea, and hirsutism (101). guided by information elicited from the client during the
medical and reproductive history and the findings of the
MMWR / April 25, 2014 / Vol. 63 / No. 4 15

physical exam. If there is no apparent cause of infertility who do not want to become pregnant should also be provided
and the client does not meet the definition above, providers preconception health services, since they are recommended by
should educate the client about how to maximize fertility (see USPSTF for the purpose of improving the health of adults.
“Clients Who Want to Become Pregnant”). ACOG notes Recommendations for improving the preconception health
the importance of addressing the emotional and educational of men also have been identified, although the evidence base
needs of clients with infertility and recommends that providers for many of the recommendations for men is less than that
consider referring clients for psychological support, infertility for women (103). This report includes preconception health
support groups, or family counseling (96). 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
Preconception Health Services health of women (e.g., through reduced STD/HIV transmission).
Providers of family planning services should offer Moreover, these services are important for improving the health
preconception health services to female and male clients of men regardless of their pregnancy intention.
in accordance with CDC’s recommendations to improve In a family planning setting, all women planning or capable
preconception health and health care (24). of pregnancy should be counseled about the need to take a daily
Preconception health services are beneficial because of supplement containing 0.4 to 0.8 mg of folic acid, in accordance
their effect on pregnancy and birth outcomes and their with the USPSTF recommendation (Grade A) (104).
role in improving the health of women and men. The term Other preconception health services for women and men
preconception describes any time that a woman of reproductive should include discussion of a reproductive life plan and
potential is not pregnant but at risk of becoming pregnant, sexual health assessment (Boxes 2 and 4), as well as the
or when a man is at risk for impregnating his female partner. screening services described below (24,103,105). Services
Preconception health-care services for women aim to identify should be provided in accordance with the cited clinical
and modify biomedical, behavioral, and social risks to a recommendations, and any needed follow up (further
woman’s health or pregnancy outcomes through prevention and diagnosis, treatment) should be provided either on-site or
management. It promotes the health of women of reproductive through referral.
age before conception, and thereby helps to reduce pregnancy- Medical History
related adverse outcomes, such as low birthweight, premature
For female clients, the medical history should include
birth, and infant mortality (24). Moreover, the preconception
the reproductive history, history of poor birth outcomes
health services recommended here are equally important
(i.e., preterm, cesarean delivery, miscarriage, and stillbirth),
because they contribute to the improvement of women’s health
environmental exposures, hazards and toxins (e.g., smoking,
and well-being, regardless of her childbearing intentions. CDC
alcohol, other drugs), medications that are known teratogens,
recommends that preconception health services be integrated
genetic conditions, and family history (24,105).
into primary care visits made by women of reproductive age,
For male clients, the medical history should include asking about
such as family planning visits (24).
the client’s past medical and surgical history that might impair his
In the family planning setting, providers may prioritize
reproductive health (e.g., genetic conditions, history of reproductive
screening and counseling about preconception health for
failures, or conditions that can reduce sperm quality, such as obesity,
couples that are trying to achieve pregnancy and couples
diabetes mellitus, and varicocele) and environmental exposures,
seeking basic infertility services. Women who are using
hazards and toxins (e.g., smoking) (103).
contraception to prevent or delay pregnancy might also
benefit from preconception health services, especially those Intimate Partner Violence
at high risk of unintended pregnancy. A woman is at high Providers should screen women of childbearing age for
risk of unintended pregnancy if she is using no method or a intimate partner violence and provide or refer women who screen
less effective method of contraception (e.g., barrier methods, positive to intervention services, in accordance with USPSTF
rhythm, or withdrawal), or has a history of contraceptive (Grade B) recommendations (106).
discontinuation or incorrect use (38,39). A woman is at lower
risk of unintended pregnancy if she is using a highly effective Alcohol and Other Drug Use
method, such as an IUD or implant, or has an established For female and male adult clients, providers should screen for
history of using methods of contraception, such as injections, alcohol use in accordance with the USPSTF recommendation
pills, patch, or ring correctly and consistently (38,39). Clients (Grade B) for how to do so, and provide behavioral counseling
16 MMWR / April 25, 2014 / Vol. 63 / No. 4

interventions, as indicated (107). Screening adults for other Height, Weight, and Body Mass Index
drug use and screening adolescents for alcohol and other drug For all clients, providers should screen adult (Grade B) and
use has the potential to reduce misuse of alcohol and other adolescent (Grade B) clients for obesity in accordance with
drugs, and can be recommended (105,108,109). However, the USPSTF recommendation, and obese adults should be
the USPSTF recommendation for screening for other drugs referred for intensive counseling and behavioral interventions
in adults, and for alcohol and other drugs in adolescents, is an to promote sustained weight loss (118,119). Clients likely will
“I,” and patients should be informed that there is insufficient need to be referred for this service. These interventions typically
evidence to assess the balance of benefits and harms of this comprise 12 to 26 sessions in a year and include multiple
screening (107,110). behavioral management activities, such as group sessions,
Tobacco Use individual sessions, setting weight-loss goals, improving diet
or nutrition, physical activity sessions, addressing barriers to
For female and male clients, providers should screen for
change, active use of self-monitoring, and strategizing how to
tobacco use in accordance with the USPSTF recommendation
maintain lifestyle changes.
(111,112) for how to do so. Adults (Grade A) who use tobacco
products should be provided or referred for tobacco cessation Blood Pressure
interventions, including brief behavioral counseling sessions For female and male clients, providers should screen for
(<10 minutes) and pharmacotherapy delivered in primary hypertension in accordance with the USPSTF’s recommendation
care settings (111). Adolescents (Grade B) should be provided (Grade A) that blood pressure be measured routinely
intervention to prevent initiation of tobacco use (112). among adults (120) and the Joint National Committee on
Immunizations Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure’s recommendation that persons with blood
For female and male clients, providers should screen for
pressure less than 120/80 be screened every 2 years, and every
immunization status in accordance with recommendations
year if prehypertensive (i.e., blood pressure 120–139/80–89)
of CDC’s Advisory Committee on Immunization Practices
(121). Providers also may follow AAP’s recommendation that
(113) and offer vaccination, as indicated, or provide referrals
adolescents receive annual blood pressure screening (109).
to community providers for immunization. Female and male
clients should be screened for age-appropriate vaccinations, Diabetes
such as influenza and tetanus–diphtheria–pertussis (Tdap), For female and male clients, providers should follow the
measles, mumps, and rubella (MMR), varicella, pneumococcal, USPSTF recommendation (Grade B) to screen for type 2
and meningococcal. In addition, ACOG recommends that diabetes in asymptomatic adults with sustained blood pressure
rubella titer be performed in women who are uncertain about (either treated or untreated) >135/80 mmHg (122).
MMR immunization (108). (For vaccines for reproductive
health-related conditions, i.e., human papillomavirus and
hepatitis B, see “Sexually Transmitted Disease Services.”) Sexually Transmitted
Depression Disease Services
For all clients, providers should screen for depression Providers should offer STD services in accordance with CDC’s
when staff-assisted depression care supports are in place to STD treatment and HIV testing guidelines (36,123,124). It
ensure accurate diagnosis, effective treatment, and follow-up is important to test for chlamydia annually among young
(114,115). Staff-assisted care supports are defined as clinical sexually active females and for gonorrhea routinely among all
staff members who assist the primary care clinician by sexually active females at risk for infection because they can
providing some direct depression care, such as care support or cause tubal infertility in women if left untreated. Testing for
coordination, case management, or mental health treatment. syphilis, HIV/AIDS, and hepatitis C should be conducted
The lowest effective staff supports consist of a screening nurse as recommended (36,123,124). Vaccination for human
who advises primary care clinicians of a positive screen and papillomavirus (HPV) and hepatitis B are also important parts
provides a protocol facilitating referral to behavioral therapy. of STD services and preconception care (113).
Providers also may follow American Psychiatric Association STD services should be provided for persons with no signs or
(116) and American Academy of Child and Adolescent symptoms suggestive of an STD. STD diagnostic management
Psychiatry (117) recommendations to assess risk for suicide recommendations are not included in these guidelines, so
among persons experiencing depression and other risk factors. providers should refer to CDC’s STD treatment guidelines
MMWR / April 25, 2014 / Vol. 63 / No. 4 17

(36) when caring for clients with STD symptoms. STD services <25 years are at highest risk for gonorrhea infection. Other risk
include the following steps, which should be provided at the factors that place women at increased risk include a previous
initial visit and at least annually thereafter: gonorrhea infection, the presence of other STDs, new or multiple
Step 1. Assess: The provider should discuss the client’s sex partners, inconsistent condom use, commercial sex work, and
reproductive life plan, conduct a standard medical history drug use. Females with gonnorrhea infection should be re-screened
and sexual health assessment (see text box above), and check for re-infection at 3 months after treatment. Pregnant women
immunization status. A pelvic exam is not indicated in patients should be screened for gonorrhea at the time of their pregnancy
with no symptoms suggestive of an STD. test if there might be delays in obtaining prenatal care (36).
Step 2. Screen: A client who is at risk of an STD For male clients, providers should screen MSM for gonorrhea
(i.e., sexually active and not involved in a mutually at anatomic sites of exposure, in accordance with CDC’s STD
monogamous relationship with an uninfected partner) should treatment guidelines (36). Males with symptoms suggestive of
be screened for HIV and the other STDs listed below, in gonorrhea (urethral discharge or dysuria or whose partner has
accordance with CDC’s STD treatment guidelines (36) and gonorrhea) should be tested and empirically treated at the initial
recommendations for HIV testing of adults, adolescents, visit. Males with gonorrhea infection should be re-screened for
and pregnant women in health-care settings (123). Clients reinfection at 3 months after treatment (36,126–128).
also should follow CDC’s recommendations for testing
Syphilis
for hepatitis C (124), and the Advisory Committee on
Immunization Practice’s recommendations on reproductive For female and male clients, providers should screen clients for
health-related immunizations (113). It is important to follow syphilis, in accordance with CDC’s STD treatment guidelines
these guidelines both to ensure that clients receive needed (36). CDC recommends that persons at risk for syphilis infection
services and to avoid unnecessary screening. should be screened. Populations at risk include MSM, commercial
sex workers, persons who exchange sex for drugs, those in adult
Chlamydia correctional facilities and those living in communities with high
For female clients, providers should screen all sexually active prevalence of syphilis (36). Pregnant women should be screened
women aged ≤25 years for chlamydia annually, in addition for syphilis at the time of their pregnancy test if there might be
to sexually active women aged >25 years with risk factors for delays in obtaining prenatal care (36).
chlamydia infection (36). Women aged >25 years at higher
HIV/AIDS
risk include sexually active women who have a new or more
than one sex partner or who have a partner who has other For female and male clients, providers should screen
concurrent partners. Females with chlamydia infection should clients for HIV/AIDS, in accordance with CDC HIV
be rescreened for re-infection at 3 months after treatment. testing guidelines (123). Providers should follow CDC
Pregnant women should be screened for chlamydia at the time recommendations that all clients aged 13–64 years be screened
of their pregnancy test if there might be delays in obtaining routinely for HIV infection and that all persons likely to be at
prenatal care (36). high risk for HIV be rescreened at least annually (123). Persons
For male clients, chlamydia screening can be considered for likely to be at high risk include injection-drug users and their
males seen at sites with a high prevalence of chlamydia, such sex partners, persons who exchange sex for money or drugs, sex
as adolescent clinics, correctional facilities, and STD clinics partners of HIV-infected persons, and MSM or heterosexual
(36,125,126). Providers should screen men who have sex with persons who themselves or whose sex partners have had more
men (MSM) for chlamydia at anatomic sites of exposure, in than one sex partner since their most recent HIV test. CDC
accordance with CDC’s STD treatment guidelines (36). Males further recommends that screening be provided after the
with symptoms suggestive of chlamydia (urethral discharge or patient is notified that testing will be performed as part of
dysuria or whose partner has chlamydia) should be tested and general medical consent unless the patient declines (opt-out
empirically treated at the initial visit. Males with chlamydia screening) or otherwise prohibited by state law. The USPSTF
infection should be re-screened for reinfection at 3 months (36). also recommends screening for HIV (Grade A) (129).
Gonorrhea Hepatitis C
For female clients, providers should screen clients for gonorrhea, For female and male clients, CDC recommends one-time
in accordance with CDC’s STD treatment guidelines (36). testing for hepatitis C (HCV) without prior ascertainment of
Routine screening for N. gonorrhoeae in all sexually active women HCV risk for persons born during 1945–1965, a population
at risk for infection is recommended annually (36). Women aged with a disproportionately high prevalence of HCV infection
18 MMWR / April 25, 2014 / Vol. 63 / No. 4

and related disease. Persons identified as having HCV is expedited partner therapy (EPT), as permissible by state laws,
infection should receive a brief screening for alcohol use and in which medication or a prescription is provided to the patient
intervention as clinically indicated, followed by referral to to give to the partner to ensure treatment. EPT is a partner
appropriate care for HCV infection and related conditions. treatment strategy for partners who are unable to access care
These recommendations do not replace previous guidelines for and treatment in a timely fashion. Because of concerns related
HCV testing that are based on known risk factors and clinical to resistant gonorrhea, efforts to bring in for treatment partners
indications. Rather, they define an additional target population of patients with gonorrhea infection are recommended; EPT
for testing: persons born during 1945–1965 (124). USPSTF for gonorrhea should be reserved for situations in which efforts
also recommends screening persons at high risk for infection to treat partners in a clinical setting are unsuccessful and EPT
for hepatitis C and one-time screening for HCV infection is a gonorrhea treatment of last resort.
for persons in the 1945–1965 birth cohort (Grade B) (130). All clients treated for chlamydia or gonorrhea should be
rescreened 3 months after treatment; HIV-infected females
Immunizations Related to Reproductive Health
with Trichomonas vaginalis should be linked to HIV care and
Female clients aged 11–26 years should be offered either rescreened for T. vaginalis at 3 months. If needed, the client also
human papillomavirus (HPV) 2 or HPV4 vaccine for the should be vaccinated for hepatitis B and HPV (113). Ideally,
prevention of HPV and cervical cancer if not previously STD treatment should be directly observed in the facility
vaccinated, although the series can be started in persons as rather than a prescription given or called in to a pharmacy.
young as age 9 years (113); recommendations include starting If a referral is made to a service site that has the necessary
at age 11–12 years and catch up vaccine among females aged medication available on-site, such as the recommended
13–26 who have not been vaccinated previously or have injectable antimicrobials for gonorrhea and syphilis, then the
not completed the 3-dose series through age 26. Routine referring provider must document that treatment was given.
hepatitis B vaccination should be offered to all unvaccinated Step 4. Provide risk counseling: If the client is at risk for
children and adolescents aged <19 years and all adults who or has an STD, high-intensity behavioral counseling for sexual
are unvaccinated and do not have any documented history of behavioral risk reduction should be provided in accordance
hepatitis B infection (113). with the USPSTF recommendation (Grade B) (132). One
Male clients aged 11–21 years (minimum age: 9 years) high-intensity behavioral counseling model that is similar to
should be offered HPV4 vaccine, if not vaccinated previously; the contraceptive counseling model is Project Respect (133),
recommendations include starting at age 11–12 years and catch which could be implemented in family planning settings. All
up vaccine among males aged 13–21 years who have not been sexually active adolescents are at risk, and adults are at increased
vaccinated previously or have not completed the 3-dose series risk if they have current STDs, had an STD in the past
through age 21 years; vaccination is recommended among year, have multiple sexual partners, are in nonmonogamous
at-risk males, including MSM and immune-compromised relationships, or are sexually active and live in a community
males through age 26 years if not vaccinated previously or with a high rate of STDs.
males who have not completed the 3-dose series through age 26 Other key messages to give infected clients before they
years. Heterosexual males aged 22–26 years may be vaccinated leave the service site include the following: a) refrain from
(131). Routine hepatitis B vaccination should be offered to all unprotected sexual intercourse during the period of STD
unvaccinated children and adolescents aged <19 years, and all treatment, 2) encourage partner(s) to be screened or to get
unvaccinated adults who do not have a documented history treatment as quickly as possible in accordance with CDC’s
of hepatitis B infection (113). STD treatment guidelines (partners in the past 60 days for
Step 3. Treat: A client with an STD and her or his chlamydia and gonorrhea, 3 to 6 months plus the duration of
partner(s) should be treated in a timely fashion to prevent lesions or signs for primary and secondary syphilis, respectively)
complications, re-infection and further spread of the infection if the partner did not accompany the client to the service site
in the community in accordance with CDC’s STD treatment for treatment, and 3) return for retesting in 3 months. If the
guidelines; clients with HIV infection should be linked to partner is unlikely to access treatment quickly, then EPT for
HIV care and treatment (36,123). Clients should be counseled chlamydia or gonorrhea should be considered, if permissible
about the need for partner evaluation and treatment to avoid by state law.
reinfection at the time the client receives the positive test A client using or considering contraceptive methods other
results. For partners of clients with chlamydia or gonorrhea, than condoms should be advised that these methods do not
one option is to schedule them to come in with the client; protect against STDs. Providers should encourage a client
another option for partners who cannot come in with the client who is not in a mutually monogamous relationship with an
MMWR / April 25, 2014 / Vol. 63 / No. 4 19

uninfected partner to use condoms. Patients who do not know Cervical cytology no longer is recommended on an annual
their partners’ infection status should be encouraged to get basis. Further, it is not recommended (Grade D) for women
tested and use condoms or avoid sexual intercourse until their aged <21 years (136). Women with abnormal test results should
infection status is known. be treated in accordance with professional standards of care,
which may include colposcopy (96,137). The need for cervical
cytology should not delay initiation or hinder continuation of
Related Preventive Health Services a contraceptive method (42).
For many women and men of reproductive age, a family Providers should also follow ACOG and AAP recommendations
planning service site is their only source of health care; that a genital exam should accompany a cervical cancer screening
therefore, visits should include provision of or referral to other to inspect for any suspicious lesions or other signs that might
preventive health services. Providers of family planning services indicate an undiagnosed STD (96,97,138).
that do not have the capacity to offer comprehensive primary Clinical Breast Examamination
care services should have strong links to other community
Despite a lack of definitive data for or against, clinical
providers to ensure that clients have access to primary care. If
breast examination has the potential to detect palpable breast
a client does not have another source of primary care, priority
cancer and can be recommended. ACOG recommends
should be given to providing related reproductive health
annual examination for all women aged >19 years (108).
services or providing referrals, as needed.
ACS recommends screening every 3 years for women aged
For clients without a primary care provider, the following
20–39 years, and annually for women aged ≥40 years (139).
screening services should be provided, with appropriate
However, the USPSTF recommendation for clinical breast
follow-up, if needed, while linking the client to a primary care
exam is an I, and patients should be informed that there is
provider. These services should be provided in accordance with
insufficient evidence to assess the balance of benefits and harms
federal and professional medical recommendations cited below
of the service (140).
regarding the frequency of screening, the characteristics of the
clients that should be screened, and the screening procedures Mammography
to be used. Providers should follow USPSTF recommendations
Medical History (Grade B) to screen women aged 50–74 years on a biennial
basis; they should screen women aged <50 years if other
USPSTF recommends that women be asked about family
conditions support providing the service to an individual
history that would be suggestive of an increased risk for
patient (140).
deleterious mutations in BRCA1 or BRCA2 genes (e.g.,
receiving a breast cancer diagnosis at an early age, bilateral Genital Examination
breast cancer, history of both breast and ovarian cancer, For adolescent males, examination of the genitals should be
presence of breast cancer in one or more female family conducted. This includes documentation of normal growth and
members, multiple cases of breast cancer in the family, both development and other common genital findings, including
breast and ovarian cancer in the family, one or more family hydrocele, varicocele, and signs of STDs (141). Components
members with two primary cases of cancer, and Ashkenazi of this examination include inspecting skin and hair, palpating
background). Women with identified risk(s) should be referred inguinal nodes, scrotal contents and penis, and inspecting the
for genetic counseling and evaluation for BRCA testing perinanal region (as indicated).
(Grade B) (134). The USPSTF also recommends that women
at increased risk for breast cancer should be counseled about
risk-reducing medications (Grade B) (135). Summary of Recommendations for
Cervical Cytology Providing Family Planning and
Providers should provide cervical cancer screening to clients Related Preventive Health Services
receiving related preventive health services. Providers should
follow USPSTF recommendations to screen women aged The screening components for each family planning and
21–65 years with cervical cytology (Pap smear) every 3 years, related preventive health service are provided in summary
or for women aged 30–65 years, screening with a combination checklists for women (Table 2) and men (Table 3). When
of cytology and HPV testing every 5 years (Grade A) (136). considering how to provide the services listed in these
recommendations (e.g., the screening components for each
20 MMWR / April 25, 2014 / Vol. 63 / No. 4

service, risk groups that should be screened, the periodicity of make changes to improve quality (147). Ideally, these steps
screening, what follow-up steps should be taken if screening will be conducted on a frequent (optimally, quarterly) and
reveals the presence of a health condition), providers should ongoing basis. However, since quality cuts across all aspects
follow CDC and USPSTF recommendations cited above, of a program, not all domains of quality can necessarily be
or, in the absence of CDC and USPSTF recommendations, considered at all times. Within a sustainable system of quality
the recommendations of professional medical associations. improvement, programs can opt to focus on a subset of quality
Following these recommendations is important both to ensure dimensions and their respective measures.
clients receive needed care and to avoid unnecessary screening
of clients who do not need the services. Determining Which Measures Are Needed
The summary tables describe multiple screening steps, which
refer to the following: 1) the process of asking questions about Performance measures provide information about how
a client’s history, including a determination of whether risk well the service site is meeting pre-established goals (148).
factors for a disease or health condition exist; 2) performing The following questions should be considered when selecting
a physical exam; and 3) performing laboratory tests in performance measures (143):
at-risk asymptomatic persons to help detect the presence of • Is the topic important to measure and report? For example,
a specific disease, infection, or condition. Many screening does it address a priority aspect of health care, and is there
recommendations apply only to certain subpopulations opportunity for improvement?
(e.g., specific age groups, persons who engage in specific risk • What is the level of evidence for the measure (e.g., that a
behaviors or who have specific health conditions), or some change in the measure is likely to represent a true change in
screening recommendations apply to a particular frequency health outcomes)? Does the measure produce consistent
(e.g., a cervical cancer screening is generally recommended (reliable) and credible (valid) results about the quality of care?
every 3 years rather than annually). Providers should be aware • Are the results meaningful and understandable and useful
that the USPSTF also has recommended that certain screening for informing quality improvement?
services not be provided because the harm outweighs the • Is the measure feasible? Can it be implemented without
benefit (see Appendix F). undue burden (e.g., captured with electronic data or
When screening results indicate the potential or actual electronic health records)?
presence of a health condition, the provider should either provide Performance measures should consider the quality of the
or refer the client for the appropriate further diagnostic testing or structure of services (e.g., the characteristics of the settings in which
treatment in a manner that is consistent with the relevant federal providers deliver health care, including material resources, human
or professional medical associations’ clinical recommendations. resources, and organizational structure), the process by which care
is provided (whether services are provided correctly and completely,
and how clients perceive the care they receive), and the outcomes
of that care (e.g., client behaviors or health conditions that result)
Conducting Quality Improvement (149). They also may assess each dimension of quality services
Service sites that offer family planning services should (10,13). Examples of measures that can be used for monitoring the
have a system for conducting quality improvement, which is quality of family planning services (150) and suggested measures
designed to review and strengthen the quality of services on an that might help providers monitor quality of care have been listed
ongoing basis. Quality improvement is the use of a deliberate (Table 6). However, other measures have been developed that also
and continuous effort to achieve measurable improvements might be useful (151–153). Service sites that offer family planning
in the identified indicators of quality of care, which improve services should select, measure, and assess at least one intermediate
the health of the community (142). By improving the quality or outcome measure on an ongoing basis, for which the service site
of care, family planning outcomes, such as reduced rates of can be accountable. Structure- and process-based measures that
unintended pregnancy, improved patient experiences, and assess the eight dimensions of quality services may be used to better
reduced costs, are more likely to be achieved (10,12,143,144). determine how to improve quality (154).
Several frameworks for conducting quality improvement
have been developed (144–146). This section presents a general
overview of three key steps that providers should take when Collecting Information
conducting quality improvement of family planning services: Once providers have determined what information is needed,
1) determine which measures are needed to monitor quality; the next steps are to collect and use that information to improve
2) collect the information needed; and 3) use the findings to the quality of care. Commonly used methods of data collection
include the following:
MMWR / April 25, 2014 / Vol. 63 / No. 4 21

TABLE 2. Checklist of family planning and related preventive health services for women
Family planning services
(provide services in accordance with the appropriate clinical recommendation)
Contraceptive Pregnancy testing and Preconception health Related preventive
Screening components services* counseling Basic infertility services services STD services† health services
History
Reproductive life plan§ Screen Screen Screen Screen Screen
Medical history§,** Screen Screen Screen Screen Screen Screen
Current pregnancy status§ Screen
Sexual health assessment§,** Screen Screen Screen Screen
Intimate partner violence §,¶,** Screen
Alcohol and other drug use§,¶,** Screen
Tobacco use§,¶ Screen (combined Screen
hormonal methods
for clients aged ≥35
years)
Immunizations§ Screen Screen for HPV &
HBV§§
Depression§,¶ Screen
Folic acid§,¶ Screen
Physical examamination
Height, weight and BMI§,¶ Screen (hormonal Screen Screen
methods)††
Blood pressure§,¶ Screen (combined Screen§§
hormonal methods)
Clinical breast exam** Screen Screen§§
Pelvic exam§,** Screen (initiating Screen (if clinically Screen
diaphragm or IUD) indicated)
Signs of androgen excess** Screen
Thyroid exam** Screen
Laboratory testing
Pregnancy test ** Screen (if clinically Screen
indicated)
Chlamydia§, ¶ Screen¶¶ Screen§§
Gonorrhea§, ¶ Screen¶¶ Screen§§
Syphilis§,¶ Screen§§
HIV/AIDS§,¶ Screen§§
Hepatitis C§,¶ Screen§§
Diabetes§,¶ Screen§§
Cervical cytology¶ Screen§§
Mammography¶ Screen§§
Abbreviations: BMI = body mass index; HBV = hepatitis B virus; HIV/AIDS = human immunodeficiency virus/acquired immunodeficiency syndrome; HPV = human papillomavirus;
IUD = intrauterine device; STD = sexually transmitted disease.
* This table presents highlights from CDC’s recommendations on contraceptive use. However, providers should consult appropriate guidelines when treating individual patients to obtain
more detailed information about specific medical conditions and characteristics (Source: CDC. U.S. medical eligibility criteria for contraceptive use 2010. MMWR 2010;59(No. RR-4).
† STD services also promote preconception health but are listed separately here to highlight their importance in the context of all types of family planning visits. The services listed in this column
are for women without symptoms suggestive of an STD.
§ CDC recommendation.
¶ U.S. Preventive Services Task Force recommendation.
** Professional medical association recommendation.
†† Weight (BMI) measurement is not needed to determine medical eligibility for any methods of contraception because all methods can be used (U.S. Medical Eligibility Criteria 1) or generally
can be used (U.S. Medical Eligibility Criteria 2) among obese women (Source: CDC. U.S. medical eligibility criteria for contraceptive use 2010. MMWR 2010;59[No. RR-4]). However, measuring
weight and calculating BMI at baseline might be helpful for monitoring any changes and counseling women who might be concerned about weight change perceived to be associated
with their contraceptive method.
§§ Indicates that screening is suggested only for those persons at highest risk or for a specific subpopulation with high prevalence of an infection or condition.
¶¶ Most women do not require additional STD screening at the time of IUD insertion if they have already been screened according to CDC’s STD treatment guidelines (Sources: CDC. STD treatment
guidelines. Atlanta, GA: US Department of Health and Human Services, CDC; 2013. Available at http://www.cdc.gov/std/treatment. CDC. Sexually transmitted diseases treatment guidelines,
2010. MMWR 2010;59[No. RR-12]). If a woman has not been screened according to guidelines, screening can be performed at the time of IUD insertion and insertion should not be delayed.
Women with purulent cervicitis or current chlamydial infection or gonorrhea should not undergo IUD insertion (U.S. Medical Eligibility Criteria 4) women who have a very high individual
likelihood of STD exposure (e.g. those with a currently infected partner) generally should not undergo IUD insertion (U.S. Medical Eligibility Criteria 3) (Source: CDC. US medical eligibility
criteria for contraceptive use 2010. MMWR 2010;59[No. RR-4]). For these women, IUD insertion should be delayed until appropriate testing and treatment occurs.
• Review of medical records. All records that detail service • Exit interview with the client. A patient is asked (through
delivery activities can be reviewed, including encounters either a written or in-person survey) to describe what
and claims data, client medical records, facility logbooks, happened during the encounter or their assessment of their
and others. It is important that records be carefully satisfaction with the visit. Both quantitative (close-ended
designed, sufficiently detailed, provide accurate questions) and qualitative (open-ended questions)
information, and have access restricted to protect methods can be used. Limitations include a bias toward
confidentiality. The use of electronic health records can clients reporting higher degrees of satisfaction, and the
facilitate some types of medical record review.
22 MMWR / April 25, 2014 / Vol. 63 / No. 4

TABLE 3. Checklist of family planning and related preventive health services for men
Family planning services
(provide services in accordance with the appropriate clinical recommendation)
Screening components and source Basic infertility Preconception Related preventive
of recommendation Contraceptive services* services health services† STD services§ health services
History
Reproductive life plan¶ Screen Screen Screen Screen
Medical history¶,†† Screen Screen Screen Screen
Sexual health assessment¶,†† Screen Screen Screen Screen
Alcohol & other drug use ¶,**,†† Screen
Tobacco use¶,** Screen
Immunizations¶ Screen Screen for HPV & HBV§§
Depression¶,** Screen
Physical examination
Height, weight, and BMI¶,** Screen
Blood pressure**,†† Screen§§
Genital exam†† Screen (if clinically Screen (if clinically Screen§§
indicated) indicated)
Laboratory testing
Chlamydia¶ Screen§§
Gonorrhea¶ Screen§§
Syphilis¶,** Screen§§
HIV/AIDS¶,** Screen§§
Hepatitis C¶,** Screen§§
Diabetes¶,** Screen§§
Abbreviations: HBV = hepatitis B virus; HIV/AIDS = human immunodeficiency virus/acquired immunodeficiency syndrome; HPV = human papillomavirus virus;
STD = sexually transmitted disease.
* No special evaluation needs to be done prior to making condoms available to males. However, when a male client requests advice on pregnancy prevention, he
should be provided contraceptive services as described in the section “Provide Contraceptive Services.”
† The services listed here represent a sub-set of recommended preconception health services for men that were recommended and for which there was a direct link
to fertility or infant health outcomes (Source: Frey K, Navarro S, Kotelchuck M, Lu M. The clinical content of preconception care: preconception care for men. Am J
Obstet Gynecol 2008;199[6 Suppl 2]:S389–95).
§ STD services also promote preconception health, but are listed separately here to highlight their importance in the context of all types of family planning visit. The
services listed in this column are for men without symptoms suggestive of an STD.
¶ CDC recommendation.
** U.S. Preventive Services Task Force recommendation.
†† Professional medical association recommendation.
§§ Indicates that screening is suggested only for those persons at highest risk or for a specific subpopulation with high prevalence of infection or other condition.
provider’s behavior might be influenced if she or he knows Consideration and Use of the Findings
clients are being interviewed.
After data are collected, they should be tabulated, analyzed,
• Facility audit. Questions about a service site’s structure
and used to improve care. Staff whose performance was assessed
(e.g., on-site availability of a broad range of FDA-approved
should be involved in the development of the data collection
methods) and processes (e.g., skills and technical
tools and analysis of results. Analysis should address the
competence of staff, referral mechanisms) can be used to
following questions (155):
determine the readiness of the facility to serve clients.
• What is the performance level of the facility?
• Direct observation. A provider’s behavior is observed
• Is there a consistent pattern of performance among
during an actual encounter with a client. Evaluation of a
providers?
full range of competencies, including communication
• What is the trend in performance?
skills, can be carried out. A main limitation is that the
• What are the causes of poor performance?
observer’s presence might influence the provider’s
• How can performance gaps be minimized?
performance.
Given the findings, service site staff should use a systematic
• Interview with the health-care provider. Providers are
approach to identifying ways to improve the quality of care.
interviewed about how specific conditions are managed.
One example of a systematic approach to improving the
Both closed- and open-ended questions can be used,
quality of care is the “Plan, Do, Study, and Act” (PDSA) model
although it is important to frame the question so that the
(147,156), in which staff first develop a plan for improving
‘correct’ answer is not suggested. A limitation is that
quality, then execute the plan on a small scale, evaluate feedback
providers tend to over-report their performance.
to confirm or adjust the plan, and finally, make the plan
MMWR / April 25, 2014 / Vol. 63 / No. 4 23

TABLE 4. Suggested measures of the quality of family planning services

Type of measure and dimension of quality Measure Source
Health outcome • Unintended pregnancy PIMS*
• Teen pregnancy
• Birth spacing
• Proportion of female users at risk for unintended pregnancy who adopt or
continue use of an FDA-approved contraceptive method (measured for any
method; highly effective methods; or long-acting reversible methods)
[Intermediate outcome]
Safe (Structure) • Proportion of providers that follow the most current CDC recommendations on
contraceptive safety
Effective • Site dispenses or provides on-site a full range of FDA-approved contraceptive methods PIMS*
(Structure, or the characteristics of the to meet the diverse reproductive needs and goals of clients; short-term hormonal,
settings in which providers deliver health long-acting reversible contraception (LARC), emergency contraception (EC).
care, including material resources, • Proportion of female users aged ≥24 years who are screened annually for chlamydial
human resources, and organizational infection.
structure) • Proportion of female users aged ≥24 years who are screened annually for gonorrhea.
• Proportion of users who were tested for HIV during the past 12 months.
• Proportion of female users aged ≥21 years who have received a Pap smear within
the past 3 years.
Client-centered • Proportion of clients who report the provider communicates well, shows respect, CAHPS†
(Process, or whether services are provided spends enough time with the client, and is informed about the client’s medical RQIP§
correctly and completely, and how history.
clients perceive the care they receive) • Proportion of clients who report that
–– Staff are helpful and treat clients with courtesy and respect.
–– His or her privacy is respected.
–– She or he receives contraceptive method that is acceptable to her or him.
Efficient • Site uses electronic health information technology or electronic health records to PIMS*
(Structure) improve client reproductive health.
Timely • Average number of days to the next appointment. PIMS*
(Structure and process) • Site offers routine contraceptive resupply on a walk-in basis.
• Site offers on-site HIV testing (using rapid technology).
• Site offers on-site HPV and hepatitis B vaccination.
Accessible • Site offers family planning services during expanded hours of operation. PIMS*
(Structure and process) • Proportion of total family planning encounters that are encounters with ongoing or CAHPS–PCMH item set
continuing users. on care coordination†
• Proportion of clients who report that his or her care provider follows up to give test
results, has up-to-date information about care from specialists, and discusses other
prescriptions.
• Site has written agreements (e.g., MOUs) with the key partner agencies for health
care (especially prenatal care, primary care, HIV/AIDS) and social service (domestic
violence, food stamps) referrals.
Equitable • Site offers language assistance at all points of contact for the most frequently PIMS*
(Structure) encountered language(s).
Value • Average cost per client. CDC¶
Abbreviations: CAPHS = Agency for Healthcare Research and Quality’s Consumer Assessment of Health Care Providers and Systems; FDA = Food and Drug Administration;
HPV = human papillomavirus; MOU = memorandum of understanding; PIMS = Performance Information and Monitoring System; RQIP = Regional Quality Indicators Program.
* Source: Fowler C. Title X Family Planning Program Performance Information and Monitoring System (PIMS): Description of Proposed Performance Measures [DRAFT].
Washington, DC: Research Triangle Institute; 2012.
† Source: Agency for Healthcare Research and Quality. Consumer Assessment of Healthcare Providers and Systems (CAHPS). Available at https://www.cahps.ahrq.
gov/default.asp.
§ Source: John Snow International. The Regional Quality Indicators Project (RQIP). Boston, MA: John Snow International; 2014. Available at http://www.jsi.com/
JSIInternet/USHealth/project/display.cfm?ctid=na&cid=na&tid=40&id=2621.
¶ Sources: Haddix A, Corso P, Gorsky R. Costs. In: Haddix A, Teutsch S, Corso P, eds. Prevention effectiveness: a guide to decision analysis and economic evaluation. 2nd
ed. Oxford, UK: Oxford University Press; 2003; Stiefel M, Nolan K. A guide to measuring the triple aim: population health, experience of care, and per capita cost.
Cambridge, MA: Institute for Healthcare Improvements; 2012.
permanent. Examples of steps that may be taken to improve Conclusion

the quality of care include developing job aids, providing
task-specific training for providers, conducting more patient The United States continues to face substantial challenges to
education, or strengthening relationships with referral sites improving the reproductive health of the U.S. population. The
through formal memoranda of understanding (146). recommendations in this report can contribute to improved
reproductive health by defining a core set of family planning
24 MMWR / April 25, 2014 / Vol. 63 / No. 4

services for women and men, describing how to provide 15. US Department of Health and Human Services, Office of Minority
contraceptive and other family planning services to both adult Health. The national standards for culturally and linguistically
appropriate services in health and health care. Washington, DC: US
and adolescent clients, and encouraging the use of the family
Department of Health and Human Services; 2012. Available at https://
planning visit to provide selected preventive health services for www.thinkculturalhealth.hhs.gov/Content/clas.asp#clas_standards.
women and men. This guidance is intended to assist primary 16. Olavarria M, Beaulac J, Belanger A, Young M, Aubry T. Organizational
care providers to offer the family planning services that will cultural competence in community health and social service
help persons and couples achieve their desired number and organizations: how to conduct a self-assessment. J Cult Divers
spacing of children and increase the likelihood that those 2009;16:140–50.
17. Frost J, Finer L, Tapales A. The impact of publicly funded family
children are born healthy. planning clinic services on unintended pregnancies and government
Recommendations are updated periodically. The most recent cost savings. J Health Care Poor Underserved 2008;19:778–96.
versions are available at http://www.hhs.gov/opa. 18. Trussell J, Henry N, Hassan F, Prezioso A, Law A, Filonenko A. Burden
of unintended pregnancy in the United States: potential savings with
References increased use of long-acting reversible contraception. Contraception
1. Finer LB, Zolna MR. Unintended pregnancy in the United States: 2013;87:154–61.
incidence and disparities, 2006. Contraception 2011;84:478–85. 19. Foster DG, Rostovtseva DP, Brindis CD, Biggs MA, Hulett D, Darney
2. CDC. Adolescent pregnancy and childbirth—United States, 1991–2008. PD. Cost savings from the provision of specific methods of
In: CDC. CDC health disparities and inequalities report—United States, contraception in a publicly funded program. Am J Public Health
2011. MMWR 2011;60(Suppl; January 14, 2011):105–8. 2009;99:446–51.
3. Martin J, Hamilton B, Osterman J, et al. Births: final data for 2012. 20. GRADE Working Group. GRADE: going from evidence to
Natl Vital Stat Rep 2013;62(9). recommendations. BMJ 2008;336:1049–51.
4. Mathews T, Macdorman M. Infant mortality statistics from the 2010 21. Institute of Medicine. Clinical practice guidelines we can trust.
period linked birth/infant data set. Natl Vital Stat Rep 2013:62(8). Washington, DC: The National Academies Press; 2011. Available at
5. US Department of Health and Human Services, Office of Population http://www.nap.edu/catalog.php?record_id=13058.
Affairs. Mission statement for the Office of Family Planning. Washington, 22. US Preventive Services Task Force. USPSTF: methods and processes.
DC: US Department of Health and Human Services; 2013. Available Rockville, MD: US Department of Health and Human Services, Agency
at http://www.hhs.gov/opa/about-opa-and-initiatives/mission. for Healthcare Research and Quality; 2013. Available at http://www.
6. Institute of medicine. Clinical preventive services for women: closing uspreventiveservicestaskforce.org/methods.htm.
the gaps. Washington, DC: The National Academies Press; 2011. 23. Lu M. Recommendations for preconception care. Am Fam Physician
Available at http://www.nap.edu/catalog.php?record_id=13181. 2007;76:397–400.
7. US Department of Health and Human Services, Office of Population 24. CDC. Recommendations to improve preconception health and health
Affairs. Title X family planning. Washington, DC: US Department of care—United States. MMWR 2006;55(No. RR-6).
Health and Human Services; 2013. Available at http://www.hhs.gov/ 25. Moos M. Preconceptional health promotion: progress in changing a
opa/title-x-family-planning/index.html. prevention paradigm. J Perinat Neonatal Nurs 2004;18:2–13.
8. Frost J. U.S. women’s use of sexual and reproductive health services: 26. American College of Obstetricians and Gynecologists. Committee Opinion
trends, sources of care and factors associated with use, 1995–2010. #512: health care for transgender individuals. Obstet Gynecol
New York, NY: Guttmacher Institute; 2013. 2011;118:1454–8.
9. US Department of Health and Human Services Coverage of certain 27. American College of Obstetricians and Gynecologists, Committee on
preventive services under the Affordable Care Act: final rules. 45 CFR Health Care for Underserved Women. ACOG Committee Opinion
Parts 147 and 156. July 19, 2010. Washington, DC: US Department No. 525: health care for lesbians and bisexual women. Obstet Gynecol
of Health and Human Services; 2010. 2012;119:1077–80.
10. Institute of Medicine. Committee on Quality of Health Care in 28. McNair R, Hegarty K. Guidelines for the primary care of lesbian, gay and
America. Crossing the quality chasm: a new health system for the 21st bisexual people: a systematic review. Ann Fam Med 2010;8:533–41.
century. Washington, DC: National Academies of Science; 2001. 29. World Professional Association for Transgender Health. Standards of
11. Bruce J. Fundamental elements of the quality of care: a simple care for the health of transsexual, transgender, and gender-
framework. Stud Fam Plann 1990;21:61–91. nonconforming people. Minneapolis, MN: World Professional
12. Becker D, Koenig MA, Kim YM, Cardona K, Sonenstein FL. The Association for Transgender Health; 2011.
quality of family planning services in the United States: findings from 30. The Center of Excellence for Transgender Health. Primary care protocol
a literature review. Perspect Sex Reprod Health 2007;39:206–15. for transgender patient care. San Francisco, CA: University of
13. Institute of Medicine. Future directions for the national health care California–San Francisco; 2011.
quality and disparities reports. Ullmer CBM, Burke S, eds. Washington, 31. American Academy of Pediatrics. Office-based care for lesbian, gay,
DC: The National Academies Press; 2010. bisexual, transgender, and questioning youth: Policy statement and
14. Tucker CM. US Department of Health and Human Services, Advisory Technical report. Pediatrics 2013;132:198–203.
Committee on Minority Health. Reducing health disparities by 32. Adelson SL, American Academy of Child and Adolescent Psychiatry
promoting patient-centered culturally and linguistically sensitive/ Committee on Quality Issues. Practice parameter on gay, lesbian or
competent health care. Rockville, MD: US Department of Health and bisexual orientation, gender nonconformity, and gender discordance
Human Services, Public Health Service; 2009. in children and adoelscents. J Am Acad Child Adolesc Psychiatry
2012;51:957–74.
MMWR / April 25, 2014 / Vol. 63 / No. 4 25

33. Office on Women’s Health. Illnesses and disabilities: sexual and 54. Huber L, Hogue C, Stein A, et al. Contraceptive use and discontinuation:
reproductive health. Available at http://www.womenshealth.gov/ findings from the contraceptive history, initiation and choice study. Am
illnesses-disabilities/your-health/sexuality-reproductive-health.cfm. J Obstet Gynecol 2006;194:1290–5.
34. McIntyre P. Adolescent friendly health services: an agenda for change. 55. CDC. Guide to community preventive services: prevention of HIV/
Geneva, Switzerland: World Health Organization; 2002. AIDS, other STIs and pregnancy, group-based comprehensive risk
35. CDC. U.S. medical eligibility criteria for contraceptive use 2010. reduction interventions for adolescents. Atlanta, GA: US Department
MMWR 2010;59(No. RR-4). of Health and Human Services, CDC; 2011. Available at www.
36. CDC. Sexually transmitted diseases treatment guidelines, 2010. thecommunityguide.org/hiv/riskreduction.html.
MMWR 2010;59(No. RR-12). 56. Kirby DB, Laris BA, Rolleri LA. Sex and HIV education programs:
37. Jaccard J. Careful, current, and consistent: tips to improve contraceptive use. their impact on sexual behaviors of young people throughout the world.
Washington, DC: National Campaign to Prevent Teen Pregnancy; 2010. J Adolesc Health 2007;40:206–17.
38. Trussell J. Contraceptive failure in the United States. Contraception 57. Oringanje C, Meremikwu MM, Eko H, Esu E, Meremikwu A, Ehiri
2011;83:397–404. JE. Interventions for preventing unintended pregnancies among
39. Winner B, Peipert J, Zhao Q, et al. Effectiveness of long-acting adolescents. Cochrane Database Syst Rev 2009:CD005215.
reversible contraception. N Engl J Med 2012;366:1998–2007. 58. English A. State minor consent laws: a summary. 3rd ed. Washington,
40. Beerthuizen R. State-of-the-art of non-hormonal methods of DC: Center for Adolescent Health and the Law; 2010.
contraception: V. Female sterilisation. Eur J Contracept Reprod Health 59. US Department of Health and Human Services. State requirements
Care 2010;15:124–35. for reporting child abuse. Washington, DC: US Department of Health
41. Michielsen D, Beerthuizen R. State-of-the art of non-hormonal and Human Services; 2013. Available at http://www.childwelfare.gov/
methods of contraception: VI. Male sterilisation. Eur J Contracept systemwide/laws_policies/state.
Reprod Health Care 2010;15:136–49. 60. Guldi M. Fertility effects of abortion and birth control pill access for
42. CDC. U.S. Selected practice recommendations for contraceptive use minors. Demography 2008;45:817–27.
2013. MMWR 2013;62(No. RR-5). 61. Klein JD, McNulty M, Flatau CN. Adolescents’ access to care: teenagers’
43. Kerns J, Westhoff C, Morroni C, Murphy P. Partner influence on early self-reported use of services and perceived access to confidential care.
discontinuation of the pill in a predominantly Hispanic population. Arch Pediatr Adolesc Med 1998;152:676–82.
Perspect Sex Reprod Health 2003;35:256–60. 62. Lehrer JA, Pantell R, Tebb K, Shafer MA. Forgone health care among
44. Forste R, Morgan J. How relationships of US men affect contraceptive U.S. adolescents: associations between risk characteristics and
use and efforts to prevent STD. Fam Plann Perspect 1998;30:56–62. confidentiality concern. J Adolesc Health 2007;40:218–26.
45. Severy L, Silver S. Two reasonable people: joint decision-making in 63. Lyren A, Kodish E, Lazebnik R, O’Riordan MA. Understanding
contraceptive choice and use. In: LJ S, ed. Advances in population: confidentiality: perspectives of African American adolescents and their
psychosocial perspectives. London, UK: Jessica Kingsley Publishers; parents. J Adolesc Health 2006;39:261–5.
1994:207–27. 64. Reddy DM, Fleming R, Swain C. Effect of mandatory parental
46. Grady W, Klepinger D. BIlly J, Cubbins L. The role of relationship notification on adolescent girls’ use of sexual health care services. JAMA
power in couple decisions about contraception in the US. J Biosoc Sci 2002;288:710–4.
2010;42:307–25. 65. Vo DX, Pate OL, Zhao H, Siu P, Ginsburg KR. Voices of Asian
47. Jaccard J. Unlocking the contraceptive conundrum. Washington, DC: American youth: important characteristics of clinicians and clinical
The National Campaign to Prevent Teen and Unplanned Pregnancy; sites. Pediatrics 2007;120:e1481–93.
2009. 66. Zabin LS, Stark HA, Emerson MR. Reasons for delay in contraceptive
48. Pallitto CC, Campbell JC, O’Campo P. Is intimate partner violence clinic utilization. Adolescent clinic and nonclinic populations
associated with unintended pregnancy? A review of the literature. compared. J Adolesc Health 1991;12:225–32.
Trauma Violence Abuse 2005;6:217–35. 67. Zavodny M. Fertility and parental consent for minors to receive
49. Paterno MT, Jordan ET. A review of factors associated with unprotected contraceptives. Am J Public Health 2004;94:1347–51.
sex among adult women in the United States. J Obstet Gynecol 68. Klein J. Achieving quality health services for adolescents: policy
Neonatal Nurs 2012;41:258–74. statement of the Committee on Adolescence, American Academy of
50. Rehm J, Shield KD, Joharchi N, Shuper PA. Alcohol consumption Pediatrics. Pediatrics 2008;121:1263.
and the intention to engage in unprotected sex: systematic review and 69. Ford C, English A, Sigman G. Confidential health care for adolescents:
meta-analysis of experimental studies. Addiction 2012;107:51–9. position paper for the Society for Adolescent Medicine. J Adolesc Health
51. Harper C, Balistreri E, Boggess J, Leon K, Darney P. Provision of 2004;35:160–7.
hormonal contraceptives without a mandatory pelvic examination: the 70. American College of Obstetricians and Gynecologists. Confidentiality in
first stop demonstration project. Fam Plann Perspect 2001;33:13–8. adolescent health care. guidelines for adolescent health care. 2nd ed.
52. Stormo A, Hawkins N, Cooper C, Saraiya M. The pelvic examination Washington, DC: American College of Obstetricians and Gynecologists; 2011.
as a screening tool: practices of US physicians. Arch Intern Med 71. Anderson NLR, Koniak-Griffin D, Keenan CK, Uman G, Duggal BR,
2011;171:2053–4. Casey C. Evaluating the outcomes of parent-child family life education.
53. Labbok M, Perez A, Valdez V, et al. The Lactational Amenorrhea Sch Inq Nurs Pract 1999;13:211–38.
Method (LAM): a postpartum introductory family planning method 72. Guilamo-Ramos V, Bouris A, Jaccard J, Gonzalez B, McCoy W, Aranda
with policy and program implications. Adv Contracept Deliv Syst D. A parent-based intervention to reduce sexual risk behavior in early
1994;10:93–109. adolescence: building alliances between physicians, social workers, and
parents. J Adolesc Health 2011;48:159–63.
26 MMWR / April 25, 2014 / Vol. 63 / No. 4

73. Blake SM, Simkin L, Ledsky R, Perkins C, Calabrese JM. Effects of a 92. Rabin JM, Seltzer V, Pollack S. The long term benefits of a
parent-child communications intervention on young adolescents’ risk for comprehensive teenage pregnancy program. Clin Pediatr (Phila)
early onset of sexual intercourse. Fam Plann Perspect 2001;33:52–61. 1991;30:305–9.
74. Brody GH, Murry VM, Gerrard M, et al. The Strong African American 93. Avellar S, Paulsell D, Sama-Miller E, Del Grosso P. Home visiting
Families Program: translating research into prevention programming. evidence of effectiveness review. Washington, DC: US Department of
Child Dev 2004;75:900–17. Health and Human Services, Office of Planning, Research and
75. Evans WD, Davis KC, Ashley OS, Blitstein J, Koo H, Zhang Y. Efficacy Evaluation, Administration for Children and Families; 2012.
of abstinence promotion media messages: findings from an online 94. Black M, Bentley M, Papas M, et al. Delaying second births among
randomized trial. J Adolesc Health 2009;45:409–16. adolescent mothers: a randomized, controlled trial of a home-based
76. Forehand R, Armistead L, Long N, et al. Efficacy of a parent-based sexual- mentoring program. Pediatrics 2006;118:1087–99.
risk prevention program for African American preadolescents: a randomized 95. American Academy of Pediatrics. Counseling the adolescent about
controlled trial. Arch Pediatr Adolesc Med 2007;161:1123–9. pregnancy options. Pediatrics 2006;101:938–40.
77. Haggerty KP, Skinner ML, MacKenzie EP, Catalano RF. A randomized 96. American College of Obstetricians and Gynecologists. Guidelines for
trial of Parents Who Care: effects on key outcomes at 24-month women’s health care: a resource manual. 3rd ed. Washington, DC:
follow-up. Prev Sci 2007;8:249–60. American College of Obstetricians and Gynecologists; 2007.
78. Huston RL, Martin LJ, Foulds DM. Effect of a program to facilitate parent- 97. American College of Obstetricians and Gynecologists. Guidelines for
child communication about sex. Clin Pediatr (Phila) 1990;29:626–33. perinatal care. 6th ed. Washington, DC: American College of
79. Lederman RP, Chan W, Roberts-Gray C. Sexual risk attitudes and Obstetricians and Gynecologists; 2007.
intentions of youth aged 12–14 years: survey comparisons of parent- 98. Ventura S, Curtin S, Abma J, Henshaw S. Estimated pregnancy rates
teen prevention and control groups. Behavioral Medicine (Washington, and rates of pregnancy outcomes for the US: 1990–2008. Natl Vital
DC) 2004;29:155–63. Stat Rep 2012;60(7).
80. Lederman RP, Chan W, Roberts-Gray C. Parent-adolescent relationship 99. Jones J. Adoption experiences of women and men and demand for
education (PARE): program delivery to reduce risks for adolescent children to adopt by women 18–44 years of age in the United States,
pregnancy and STDs. Behav Med 2008;33:137–43. 2002. Vital Health Stat 2008;23(7).
81. Lefkowitz ES, Sigman M, Au TK. Helping mothers discuss sexuality 100. American Society for Reproductive Medicine in collaboration with the
and AIDS with adolescents. Child Dev 2000;71:1383–94. Society for Reproductive Endocrinology and Infertility. Optimizing
82. Miller BC, Norton MC, Jenson GO. Pregnancy prevention programs: natural fertility. Fertil Steril 2008;90(Suppl):S1–6.
Impact Evaluation of Facts and Feelings: a home-based video sex 101. American Society for Reproductive Medicine. Optimal evaluation of
education curriculum. Fam Relat 1993;42:392–400. the infertile female. Fertil Steril 2006;86.
83. Murry VM, Berkel C, Brody GH, Gerrard M, Gibbons FX. The Strong 102. American Urological Association. The optimal evaluation of the infertile
African American Families program: longitudinal pathways to sexual male: AUA best practice statement. Linthicum, MD: American
risk reduction. J Adolesc Health 2007;41:333–42. Urological Association; 2010.
84. Schuster MA, Corona R, Elliott MN, et al. Evaluation of Talking 103. Frey K, Navarro S, Kotelchuck M, Lu M. The clinical content of
Parents, Healthy Teens, a new worksite based parenting programme to preconception care: preconception care for men. Am J Obstet Gynecol
promote parent-adolescent communication about sexual health: 2008;6:S389–95.
randomised controlled trial. BMJ 2008;337:a308. 104. US Preventive Services Task Force. Folic acid to prevent neural tube
85. Stanton B, Cole M, Galbraith J, et al. Randomized trial of a parent defects. Rockville, MD: US Department of Health and Human
intervention: parents can make a difference in long-term adolescent Services, Agency for Healthcare Research and Quality; 2009. Available
risk behaviors, perceptions, and knowledge. Arch Pediatr Adolesc Med at http://www.uspreventiveservicestaskforce.org/uspstf/uspsnrfol.htm.
2004;158:947–55. 105. Jack B, Atrash H, Coonrod D, Moos M, O’Donnell J, Johnson K. The
86. Stanton BF, Li X, Galbraith J, et al. Parental underestimates of clinical content of preconception care: an overview and preparation of
adolescent risk behavior: a randomized, controlled trial of a parental this supplement. Am J Obstet Gynecol 2008;199(Suppl B):S266–79.
monitoring intervention. J Adolesc Health 2000;26:18–26. 106. US Preventive Services Task Force. Screening for intimate partner
87. American Academy of Pediatrics. Parents matter: your children want violence and abuse of elderly and vulnerable adults. Rockville, MD:
to learn about the facts of life from you. Elk Grove Village, IL: American US Department of Health and Human Services, Agency for Healthcare
Academy of Pediatrics; ND. Available at http://www2.aap.org/visit/ Research and Quality; 2013. Available at http://www.
ParentsMatterBrochure.pdf. uspreventiveservicestaskforce.org/uspstf/uspsipv.htm.
88. Hamilton B. Births: final Data for 2010. National Vital Statistics 107. US Preventive Services Task Force. Screening and Behavioral
Reports 2012;61(1). Counseling Interventions in Primary Care to Reduce Alcohol Misuse.
89. Olds DL, Henderson CR Jr, Tatelbaum R, Chamberlin R. Improving AHRQ, US Department of Health and Human Services; 2013.
the life-course development of socially disadvantaged mothers: a 108. American College of Obstetricians and Gynecologists. Committee
randomized trial of nurse home visitation. Am J Public Health Opinion No. 483: primary and preventive care: periodic assessments.
1988;78:1436–45. Obstet Gynecol 2011;117:1008–15.
90. Olds DL, Kitzman H, Cole R, et al. Effects of nurse home-visiting on 109. Committee on Practice and Ambulatory Medicine, Bright Futures
maternal life course and child development: age 6 follow-up results of Periodicity Schedule Workgroup. 2014 recommendations for pediatric
a randomized trial. Pediatrics 2004;114:1550–9. preventive health care. Pediatrics 2014;133;568.
91. Olds DL, Kitzman H, Hanks C, et al. Effects of nurse home visiting 110. US Preventive Services Task Force. Screening for illicit drug use.
on maternal and child functioning: age-9 follow-up of a randomized Rockville, MD: US Department of Health and Human Services, Agency
trial. Pediatrics 2007;120:e832–45. for Healthcare Research and Quality; 2008.
MMWR / April 25, 2014 / Vol. 63 / No. 4 27

111. US Preventive Services Task Force. Counseling and interventions to 126. Burstein GR, Eliscu A, Ford K, et al. Expedited partner therapy for
prevent tobacco use and tobacco-caused disease in adults and pregnant adolescents diagnosed with chlamydia or gonorrhea: a position paper
women. Rockville, MD: US Department of Health and Human of the Society for Adolescent Medicine. J Adolesc Health
Services, Agency for Healthcare Research and Quality; 2009. Available 2009;45:303–9.
at http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac2.htm. 127. American Academy of Pediatrics. Promoting healthy sexual development
112. US Preventive Services Task Force. Primary care interventions to prevent and sexuality. Bright Futures: guidelines for health supervision of
tobacco use in children and adolescents. Rockville, MD: US infants, children, and adolescents. Elk Grove, IL: American Academy
Department of Health and Human Services, Agency for Healthcare of Pediatrics; 2007.
Research and Quality; 2013. 128. US Preventive Services Task Force. Screening for gonorrhea. Rockville,
113. CDC. Advisory Committee on Immunization Practices (ACIP) MD: US Department of Health and Human Services, Agency for
recommended immunization schedules for persons aged 0 through 18 Healthcare Research and Quality; 2005. Available at http://www.
years and adults aged 19 years and older—United States, 2013. MMWR uspreventiveservicestaskforce.org/uspstf/uspsgono.htm.
2013;62(Suppl 1):1–19. 129. US Preventive Services Task Force. Screening for HIV. Rockville, MD: US
114. US Preventive Services Task Force. Screening for depression in adults. Department of Health and Human Services, Agency for Healthcare Research
Rockville, MD: US Department of Health and Human Services, Agency and Quality; 2013. Available at http://www.uspreventiveservicestaskforce.
for Healthcare Research and Quality; 2009. Available at http://www. org/uspstf/uspshivi.htm.
uspreventiveservicestaskforce.org/uspstf/uspsaddepr.htm. 130. US Preventive Services Task Force. Screening for hepatitis C virus
115. US Preventive Services Task Force. Major depressive disorder in children infection in adults. Rockville, MD: US Department of Health and
and adolescents. Rockville, MD: US Department of Health and Human Human Services, Agency for Healthcare Research and Quality; 2013.
Services, Agency for Healthcare Research and Quality; 2009. Available Available at http://www.uspreventiveservicestaskforce.org/uspstf12/
at http://www.uspreventiveservicestaskforce.org/uspstf/uspschdepr.htm. hepc/hepcfinalrs.htm#recommendations.
116. American Psychiatric Association. Practice guideline for the assessment 131. CDC. Recommendations on the use of quadrivalent human
and treatment of patients with suicidal behaviors. Am J Psychiatry papillomavirus vaccine in males—Advisory Committee on
2003;160(Suppl):1–60. Immunization Practices (ACIP). MMWR 2011;60:1705–8.
117. American Academy of Child and Adolescent Psychiatry. Practice 132. US Preventive Services Task Force. Behavioral counseling to prevent
parameter for the assessment and treatment of children and adolescents sexually transmitted infections. Rockville, MD: US Department of
with suicidal behavior. J Am Acad Child Adolesc Psychiatry Health and Human Services, Agency for Healthcare Research and
2001;40(Suppl):24S–51S. Quality; 2008. Available at http://www.uspreventiveservicestaskforce.
118. US Preventive Services Task Force. Screening for obesity in children and org/uspstf/uspsstds.htm.
adolescents: US Preventive Services Task Force recommendation 133. Kamb ML, Fishbein M, Douglas JM Jr, et al. Efficacy of risk-reduction
statement. Rockville, MD: US Department of Health and Human counseling to prevent human immunodeficiency virus and sexually
Services, Agency for Healthcare Research and Quality; 2010. Available transmitted diseases: a randomized controlled trial. Project RESPECT
at http://www.uspreventiveservicestaskforce.org/uspstf/uspschobes.htm. Study Group. JAMA 1998;280:1161–7.
119. US Preventive Services Task Force. Screening for and management of 134. US Preventive Services Task Force. Risk assessment, genetic counseling,
obesity in adults. Rockville, MD: US Department of Health and and genetic testing for BRCA-related cancer in women. Rockville, MD:
Human Services, Agency for Healthcare Research and Quality; 2012. US Department of Health and Human Services, Agency for Healthcare
Available at http://www.uspreventiveservicestaskforce.org/uspstf11/ Research and Quality; 2013. Available at http://www.
obeseadult/obesers.htm. uspreventiveservicestaskforce.org/uspstf/uspsbrgen.htm.
120. US Preventive Services Task Force. Screening for high blood pressure 135. US Preventive Services Task Force. Medications for risk reduction of
in adults. Rockville, MD: US Department of Health and Human primary breast cancer in women. Rockville, MD: US Department of
Services, Agency for Healthcare Research and Quality; 2007. Available Health and Human Services, Agency for Healthcare Research and
at http://www.uspreventiveservicestaskforce.org/uspstf/uspshype.htm. Quality; 2013. Available at http://www.uspreventiveservicestaskforce.
121. US Department of Health and Human Services. The seventh report org/uspstf/uspsbrpv.htm.
of the Joint National Committee on the Prevention, Detection, 136. US Preventive Services Task Force. Screening for cervical cancer.
Evaluation, and Treatment of High Blood Pressure. Washington, DC: Rockville, MD: US Department of Health and Human Services, Agency
US Department of Health and Human Services; 2004. for Healthcare Research and Quality; 2012. Available at www.
122. US Preventive Services Task Force. Screening for type 2 diabetes mellitus uspreventiveservicestaskforce.org/uspstf11/cervcancer/cervcancerrs.htm.
in adults. Rockville, MD: US Department of Health and Human 137. Massad L, Einstein M, Huh W, et al. 2012 updated consensus guidelines
Services, Agency for Healthcare Research and Quality; 2008. Available for the management of abnormal cervical cancer screening tests and
at http://www.uspreventiveservicestaskforce.org/uspstf/uspsdiab.htm. cancer precursors. Obstet Gynecol 2013;121:829–46.
123. CDC. Revised recommendations for HIV testing of adults, adolescents and 138. Braverman P, Breech L. Gynecologic examination for adolescents in
pregnant women in health care settings. MMWR 2006;55(No. RR-14). the pediatric office setting. Pediatrics 2010;126:583–90.
124. CDC. Recommendations for the identification of chronic hepatitis C 139. Smith RA, Brooks D, Cokkinides V, Saslow D, Brawley OW. Cancer
virus infection among persons born during 1945–1965. MMWR screening in the United States, 2013: a review of current American
2012;61(No. RR-4). Cancer Society guidelines, current issues in cancer screening, and new
125. CDC. Male chlamydia screening consultation. Atlanta, GA: US guidance on cervical cancer screening and lung cancer screening. CA
Department of Health and Human Services, DCD; 2006. Available at Cancer J Clin 2013;63:88–105.
http://www.cdc.gov/std/chlamydia.
28 MMWR / April 25, 2014 / Vol. 63 / No. 4

140. US Preventive Services Task Force. Screening for breast cancer. 149. Donabedian A. The quality of care. JAMA 1988;260:1743–8.
Rockville, MD: US Department of Health and Human Services, Agency 150. Fowler C. Title X Family Planning Program Performance Information
for Healthcare Research and Quality; 2009. Available at http://www. and Monitoring System (PIMS): description of proposed performance
uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm. measures. Washington, DC: Research Triangle Institute; 2012.
141. Marcell A, Bell D, Joffe A. The male genital examination: a position 151. California Family Health Council. Performance measures: guiding
paper of the Society for Adolescent Health and Medicine: a position quality improvement for family planning services. Los Angeles, CA:
paper of the Society for Adolescent Health and Medicine. J Adolesc California Family Health Council; 2011. Available at http://www.cfhc.
Health 2012;50:424–5. org/TitleX/PerformanceMeasures/default.htm.
142. Riley W, Moran J, Corso L, Beitsch L, Bialek R, Cofsky A. Defining 152. John Snow International. The Regional Quality Indicators Project
quality improvement in public health. J Public Health Manag Pract (RQIP). Boston, MA: John Snow International; 2012. Available at
2010;16:5–7. http://www.jsi.com/JSIInternet/USHealth/project/display.cfm?ctid=n
143. National Quality Forum. ABCs of measurement. Washington, DC: a&cid=na&tid=40&id=2621.
National Quality Forum; 2011. Available at http://www.qualityforum. 153. Family Planning Councils of America. Performance Measurement
org/Measuring_Performance/ABCs_of_Measurement.aspx. System. Los Angeles, CA: Family Planning Councils of America; ND.
144. Berwick D, Nolan T, Whittington J. The Trip Aim: care, health and Available at http://www.fpcai.org/pms.html.
cost. Health Aff 2008;27:759–69. 154. Palmer R. Process-based measures of quality: the need for detailed
145. CDC. National Public Health Performance Standards Program. Atlanta, clinical data in large health care databases. Ann Intern Med 1997;
GA: US Department of Health and Human Services, CDC; 2012. 127:733–8.
Available at www.cdc.gov/od/ocphp/nphpsp. 155. Bouchet B. Health manager’s guide: monitoring the quality of primary
146. Berwick D. A user’s manual for the IOM’s “Quality Chasm” Report. care. Bethesda, MD: Center for Human Services; ND. Available at
Health Affairs 2002;21:80–90. http://pdf.usaid.gov/pdf_docs/PNACK584.pdf.
147. Langley G, Nolan K, Nolan T, Norman C, Provost L. The Improvement 156. Institute for Health Care Improvement. How to improve. Cambridge,
Guide: A practical approach to enhancing organizational performance. MA: Institute for Health Care Improvement; 2014. Available at http://
2nd ed. San Francisco, CA: Jossey-Bass Publishers; 2009. www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx.
148. Government Accountability Office. Performance measurement and
evaluation: definitions and relationships. Washington, DC:
Government Accountability Office; 2011.
MMWR / April 25, 2014 / Vol. 63 / No. 4 29

Appendix A
How the Recommendations Were Developed
The recommendations were developed jointly under the to consider the quality of the evidence and suggest what
auspices of CDC’s Division of Reproductive Health (DRH) recommendations might be justified on the basis of the
and the Office of Population Affairs (OPA), in consultation evidence. CDC and OPA used this feedback to develop core
with a wide range of experts and key stakeholders. A recommendations for counseling, serving adolescents, and
multistage process that drew on established procedures for quality improvement. EWG members subsequently reviewed
developing clinical guidelines (1,2) was used to develop the these core recommendations; EWG members differed from the
recommendations. In April 2010, an Expert Work Group subject matter experts in that they were more familiar with the
(EWG) comprising family planning clinical providers, program family planning service delivery context and could comment
administrators, representatives from relevant federal agencies, on the feasibility and appropriateness of the recommendations
and representatives from professional medical organizations as well as on their scientific justification. EWG members met
was created to advise OPA and CDC on the structure and to consider the core recommendations using 1) the quality
content of the revised recommendations and to help make the of the evidence; 2) the positive and negative consequences of
recommendations more feasible and relevant to the needs of implementing the recommendations on health outcomes, costs
the field. This group made two key initial recommendations: or cost-savings, and implementation challenges; and 3) the
1) to examine the scientific evidence for three priority areas of relative importance of these consequences (e.g., the ability of
focus identified as key components of family planning service the recommendations to have a substantial effect on health
delivery, (i.e., counseling and education, serving adolescents, outcomes may be weighed more than the logistical challenges
and quality improvement); and 2) to guide providers of family of implementing them) (1). In certain cases, when the evidence
planning services in the use of various recommendations for was inconclusive or incomplete, recommendations were made on
how to provide clinical care to women and men. the basis of expert opinion (see Appendix B). Finally, CDC and
OPA staff considered the feedback from EWG members when
finalizing the core recommendations and writing this report.
Developing Recommendations on
Counseling, Adolescent Services, Developing Recommendations
and Quality Improvement on Clinical Services
Systematic reviews of the published literature from January 1985
through December 2010 were conducted for each priority topic DRH and OPA staff members synthesized recommendations
to identify evidence-based and evidence-informed approaches to for clinical care for women and for men that were developed
family planning service delivery. Standard methods for conducting by >35 federal and professional medical organizations. They
the reviews were used, including the development of key questions were assisted in this effort by staff from OPA’s Office of Family
and analytic frameworks, the identification of the evidence base Planning Male Training Center and from CDC’s Division of
through a search of the published as well as “gray literature” STD Prevention, Division of Violence Prevention, Division
(i.e., studies published somewhere other than in a peer-reviewed of Immunization Services, and Division of Cancer Prevention
journal), and a synthesis of the evidence in which findings were and Control. The synthesis was needed because clinical
summarized and the quality of individual studies was considered, recommendations are sometimes inconsistent with each other
using the methodology of the U.S. Preventive Services Task Force and can vary by the extent to which they are evidence-based.
(USPSTF) (3). Eight databases were searched (i.e., MEDLINE, The clinical recommendations addressed contraceptive services,
PsychInfo, PubMed, CINAHL, Cochrane, EMBASE, POPLINE, achieving pregnancy, basic infertility services, preconception
and the U.K. National Clearinghouse Service Economic health services, sexually transmitted disease services, and related
Evaluation Database) and were restricted to literature from the health-care services.
United States and other developed countries. Summaries of the An attempt was made to apply the Institute of Medicine’s
evidence used to prepare these recommendations will appear in criteria for clinical practice guidelines when deciding which
background papers that will be published separately. professional medical organizations to include in the review (2).
In May 2011, three technical panels (one for each priority However, many organizations did not articulate the process
topic) comprising subject matter experts were convened used to develop the recommendations fully, and many did not
30 MMWR / April 25, 2014 / Vol. 63 / No. 4

conduct comprehensive and systematic reviews of the literature. at high risk of unintended pregnancy). Future operational
In the end, to be included in the synthesis, the recommending research should provide more information about how to deliver
organization had to be a federal agency or major professional these services most efficiently during multiple visits to clients
medical organization that represents established medical with diverse needs.
disciplines. In addition, a recommendation had to be made on
the basis of an independent review of the evidence or expert
opinion and be considered a primary source that was developed Determining How Clinical Services
for the United States.
In July 2011, two technical panels comprising subject matter
Should Be Provided
experts on clinical services for women and men were convened Various federal agencies and professional medical associations
to review the synthesis of federal and professional medical have made recommendations for how to provide family
recommendations, reconcile inconsistent recommendations, planning services. When considering these recommendations,
and provide individual feedback to CDC and OPA about the the Expert Work Group used the following hierarchy:
implications for family planning service delivery. CDC and OPA • Highest priority was given to CDC guidelines because
used this individual feedback to develop core recommendations they are developed after a rigorous review of scientific
for clinical services. The core recommendations were subsequently evidence. CDC guidelines tailor recommendations for
reviewed by EWG members, and feedback was used to finalize higher risk individuals, (whereas USPSTF focuses on
the core recommendations and write this report. average risk individuals), who are more representative of
Members of the technical panels recommended that the clients seeking family planning services.
contraceptive services, pregnancy testing and counseling, • When no CDC guideline existed to guide the
services to achieve pregnancy, basic infertility care, STD services, recommendations, the relevant USPSTF A or B
and other preconception health services should be considered recommendations (which indicate a high or moderate
family planning services. This feedback considered federal certainty that the benefit is moderate to substantial) were
statute and regulation, CDC and USPSTF recommendations used. USPSTF recommendations are made on the basis of
for clinical care, and EWG members’ opinion. a thorough review of the available evidence.
Because CDC’s preconception health recommendations • If neither a CDC nor a USPSTF A or B recommendation
include many services, the panel narrowed the range of existed, the recommendations of selected major professional
preconception services that were included by using the following medical associations were considered as resources. The
criteria: 1) the Select Panel on Preconception Care (4) had American Academy of Pediatrics’ (AAP) Bright Futures
assigned an A or B recommendation to that service for women, guidelines (6) were used as the primary source of
which means that there was either good or fair evidence to recommendations for adolescents when no CDC or
support the recommendation that the condition be considered USPSTF recommendations existed.
in a preconception care evaluation (Table 1), or 2) the service • For a limited number of recommendations, there were no
was included among recommendations made by experts in federal or major professional medical recommendations, but
preconception health for males (5). Services for men that the service was recommended by EWG members on the basis
addressed health conditions that affect reproductive capacity of expert opinion for family planning clients.
or pregnancy outcomes directly were included as preconception In some cases, a service was graded as an I recommendation
health; services that addressed men’s health but that were not by USPSTF for the general population (an I recommendation
related directly to pregnancy outcomes were considered to be means that the current evidence is insufficient to assess the balance
related preventive health services. of benefits and harms of the service, so if the service is offered,
The Expert Work Group noted that more preventive services patients should be informed of this fact), but either CDC, EWG
are recommended than can be offered feasibly in some settings. members, or another organization recommended the service for
However, a primary purpose of this report is to set a broad women or men seeking family planning services. The situations
framework within which individual clinics will tailor services in which this occurred and the reasons why the service was
to meet the specific needs of the populations that they serve. recommended despite its receiving an I recommendation by
In addition, EWG members identified specific subgroups that USPSTF have been summarized (Table 2). The approach used to
should have the greatest priority for preconception health consider the evidence and make recommendations that are used
services (i.e., those trying to achieve pregnancy and those by USPSTF have been summarized (Tables 3 and 4) (7).
MMWR / April 25, 2014 / Vol. 63 / No. 4 31

References 5. Frey KA, Navarro S, Kotelchuck M, Lu M. The clinical content of

preconception care: preconception care for men. Am J Obstet Gynecol
1. GRADE Working Group. GRADE: going from evidence to
2008;199(Suppl 2):S389–95.
recommendations. BMJ 2008;336:1049–51.
6. Committee on Practice and Ambulatory Medicine, Bright Futures
2. Institute of Medicine. Clinical practice guidelines we can trust. Washington,
Periodicity Schedule Workgroup. 2014 recommendations for pediatric
DC: The National Academies Press; 2011. Available at http://www.nap.
preventive health care. Pediatrics 2014;133;568.
edu/catalog.php?record_id=13058.
7. US Preventive Services Task Force. Grade definitions. Rockville, MD: US
3. US Preventive Services Task Force. USPSTF: methods and processes.
Department of Health and Human Services, Agency for Healthcare Research
Rockville, MD: US Department of Health and Human Services, Agency
and Quality; 2013. Available at http://www.uspreventiveservicestaskforce.
for Healthcare Research and Quality; 2013. Available at http://www.
org/uspstf/grades.htm.
uspreventiveservicestaskforce.org/methods.htm.
4. Jack BW, Atrash H, Coonrod D, Moos M, O’Donnell J, Johnson K. The
clinical content of preconception care: an overview and preparation of this
supplement. Am J Obstet Gynecol 2008;199(Suppl 2):S266–79.
32 MMWR / April 25, 2014 / Vol. 63 / No. 4

TABLE 1. Select Panel on Preconception Care grading system

Quality of the evidence*
I-a Evidence was obtained from at least one properly conducted, randomized, controlled trial that was performed with subjects who were not pregnant.
I-b Evidence was obtained from at least one properly conducted, randomized, controlled trial that was done not necessarily before pregnancy.
II-1 Evidence was obtained from well-designed, controlled trials without randomization.
II-2 Evidence was obtained from well-designed cohort or case-control analytic studies, preferably conducted by more than one center or research group.
II-3 Evidence was obtained from multiple-time series with or without the intervention, or dramatic results in uncontrolled experiments.
III Opinions were gathered from respected authorities on the basis of clinical experience, descriptive studies and case reports, or reports of expert
committees.
Strength of the recommendation
A There is good evidence to support the recommendation that the condition be considered specifically in a preconception care evaluation.
B There is fair evidence to support the recommendation that the condition be considered specifically in a preconception care evaluation.
C There is insufficient evidence to recommend for or against the inclusion of the condition in a preconception care evaluation, but recommendation to
include or exclude may be made on other grounds.
D There is fair evidence to support the recommendation that the condition be excluded in a preconception care evaluation.
E There is good evidence to support the recommendation that the condition be excluded in a preconception care evaluation.
Source: Jack B, Atrash H, Coonrod D, Moos M, O’Donnell J, Johnson K. The clinical content of preconception care: an overview and preparation of this supplement.
Am J Obstet Gynecol 2008;199(6 Suppl 2):S266–79.
TABLE 2. Services included in these recommendations that received a U.S. Preventive Services Task Force (USPSTF) I recommendation
Service/screen USPSTF recommendation Why the service is recommended despite a USPSTF I recommendation
Alcohol I for adolescents The recommendations are consistent with CDC’s recommendations on preconception health and
AAP’s Bright Futures* guidelines.
Other drugs I for adolescents and adults The recommendations are consistent with CDC’s recommendations on preconception health and
AAP’s Bright Futures guidelines.
Clinical breast exam I for all women No CDC recommendation exists, but ACOG and ACS recommend conducting clinical breast exams,
and the Expert Work Group endorsed the ACOG recommendation.
Chlamydia I for all males The recommendations are consistent with CDC’s STD treatment guidelines.
Gonorrhea I for all males The recommendations are consistent with CDC’s STD treatment guidelines.
Source: US Preventive Services Task Force. USPSTF recommendations. Available at http://www.uspreventiveservicestaskforce.org/recommendations.htm.
Abbreviations: AAP = American Academy of Pediatrics; ACS = American Cancer Society; ACOG = American Congress of Obstetricians and Gynecologists; STD = sexually
transmitted disease.
* Source: Committee on Practice and Ambulatory Medicine, Bright Futures Periodicity Schedule Workgroup. 2014 recommendations for pediatric preventive health
care. Pediatrics 2014;133;568.
MMWR / April 25, 2014 / Vol. 63 / No. 4 33

TABLE 3. U.S. Preventive Services Task Force (USPSTF) grades, definitions, and suggestions for practice
Grade Definition Suggestions for practice
A USPSTF recommends the service. There is high certainty that the net This service should be offered or provided.
benefit is substantial.
B USPSTF recommends the service. There is high certainty that the net This service should be offered or provided.
benefit is moderate, or there is moderate certainty that the net
benefit is moderate to substantial.
C Clinicians may provide this service to selected patients depending on This service should be offered or provided only if other
individual circumstances. However, for a majority of persons without considerations support the offering or providing the service in an
signs or symptoms there is likely to be only a limited benefit from individual patient.
this service.
D USPSTF recommends against the service. There is moderate or high Use of this service should be discouraged.
certainty that the service has no net benefit or that the harms
outweigh the benefits.
I Statement USPSTF concludes that the current evidence is insufficient to assess The clinical considerations section of USPSTF recommendation
the balance of benefits and harms of the service. Evidence is lacking, statement should be consulted. If the service is offered, patients
of poor quality, or conflicting, and the balance of benefits and harms should be educated about the uncertainty of the balance of
cannot be determined. benefits and harms.
Source: US Preventive Services Task Force. USPSTF: methods and processes. Available at http://www.uspreventiveservicestaskforce.org/methods.htm.
TABLE 4. Levels of certainty regarding net benefit

Level of certainty* Description
High The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care
populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be
strongly affected by the results of future studies.
Moderate The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is
constrained by such factors as
• the number, size, or quality of individual studies;
• inconsistency of findings across individual studies;
• limited generalizability of findings to routine primary care practice; and
• lack of coherence in the chain of evidence.
As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large
enough to alter the conclusion.
Low The available evidence is insufficient to assess effects on health outcomes is insufficient because of
• the limited number or size of studies,
• important flaws in study design or methods,
• inconsistency of findings across individual studies,
• gaps in the chain of evidence,
• findings not generalizable to routine primary care practice,
• lack of information on important health outcomes, or
• more information required to allow estimation of effects on health outcomes.
Source: US Preventive Services Task Force. USPSTF: methods and processes. Available at http://www.uspreventiveservicestaskforce.org/methods.htm.
* The US Preventive Services Task Force (USPSTF) defines certainty as the likelihood that the USPSTF assessment of the net benefit of a preventive service is correct.
The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. USPSTF assigns a certainty level
on the basis of the nature of the overall evidence available to assess the net benefit of a preventive service.
34 MMWR / April 25, 2014 / Vol. 63 / No. 4

Appendix B
The Evidence, Potential Consequences, and Rationales for Core Recommendations
Sixteen core recommendations that were considered by life plan; medical history; sexual health assessment; intimate
the Expert Work Group (EWG) are presented below. Each partner violence, alcohol, and other drug use; tobacco use;
recommendation is accompanied by a summary of the immunizations; depression; body mass index (BMI); blood
relevant evidence (full summaries of which will be published pressure; chlamydia, gonorrhea, syphilis, and HIV/AIDS; and
separately), a list of potential consequences of implementing diabetes. All female clients also should be counseled about the
the recommendation, and its rationale. When considering the need to take a daily supplement of folic acid. When screening
recommendations, the Expert Work Group was divided into results indicate the presence of a health condition, the provider
two groups (one comprising seven members and the other five should take steps either to provide or to refer the client for
members), and each group considered separate recommendations. the appropriate further diagnostic testing and or treatment.
Services should be provided in a manner that is consistent
with established federal and professional medical associations’
Definition of Family recommendations to enable clients who need services to receive
them and to avoid over-screening.
Planning Services Quality of evidence: A systematic review was not conducted;
Recommendation: Primary care providers should offer the the recommendation was made on the basis of CDC’s
following family planning services: contraceptive services for recommendations to improve preconception health and health
women and men who want to prevent pregnancy and space care (3) and a review of preconception health services by an
births, pregnancy testing and counseling, help for clients who expert panel on preconception care for women (6).
wish to achieve pregnancy, basic infertility services, sexually Potential consequences: More women will receive specified
transmitted disease (STD) services and preconception health preconception health services, which will improve the health of
services to improve the health of women, men, and infants. infants and women. The evidence base for preconception health
Quality of evidence: A systematic review was not conducted; is not fully established. There is a potential risk that a client with
the recommendation was made on the basis of federal statute a positive screen will not be able to afford treatment if the client is
and regulation (1,2), CDC clinical recommendations (3–5), uninsured and not eligible for public programs. The human and
and expert opinion. financial cost of providing preconception health services might
Potential consequences: Adding preconception health mean that fewer contraceptive and other services can be offered.
services means that more women and men will receive Rationale: The potential benefits to the health of women and
preconception health services. The recommended services infants were thought by the panel to be greater than the costs,
also will promote the health of women and men even if potential harms, and opportunity costs of providing these services.
they do not have children. The human and financial cost of Implementation (e.g., training and monitoring of providers) can
providing preconception health services might mean that fewer address the issues related to providers over-screening and not
contraceptive and other services can be offered in some settings. following the federal and professional medical recommendations.
Rationale: Services to prevent and achieve pregnancy CDC will continue to monitor related research and modify these
are core to the federal government’s efforts to promote recommendations, as needed. Health-care reform might make
reproductive health. Adding preconception health as a family follow-up care more available to low-income clients. All seven
planning service is consistent with this mission; it emphasizes EWG members agreed to this recommendation.
achieving a healthy pregnancy and also promotes adult health.
Adding preconception health is also consistent with CDC
recommendations to integrate preconception health services Preconception Health — Men
into primary care platforms (3). All seven EWG members
agreed to this recommendation. Recommendation: Preconception health services for men
include the following screening services: reproductive life
plan; medical history; sexual health assessment; alcohol and
other drug use; tobacco use; immunizations; depression;
Preconception Health — Women BMI; blood pressure; chlamydia, gonorrhea, syphilis, and
Recommendation: Preconception health services for HIV/AIDS; and diabetes. When screening results indicate
women include the following screening services: reproductive the presence of a health condition, the provider should take
MMWR / April 25, 2014 / Vol. 63 / No. 4 35

steps either to provide or to refer the client for the appropriate Quality of evidence: Twenty-two studies were identified
further diagnostic testing and or treatment. Services should be that examined the impact of contraceptive counseling
provided in a manner that is consistent with established federal in clinical settings and met the inclusion criteria. Of the
and professional medical associations’ recommendations to 16 studies that focused on adults or mixed populations
ensure that clients who need services receive them and to avoid (adolescents and adults) (8–23), 11 found a statistically
over-screening. significant positive impact of counseling interventions with low
Quality of evidence: A systematic review was not conducted; (11,12,14–16,18–21), moderate (8), or unrated (22) intensity
the recommendation was made on the basis of CDC’s on at least one outcome of interest; study designs included two
recommendations to improve preconception health and cross-sectional surveys (14,22), one pre-post study (21), one
health care (3) and a review of preconception health services prospective cohort study (8), one controlled trial (15), and
for men (7). six randomized controlled trials (RCTs) (11,12,16,18–20).
Potential consequences: More men will receive Six studies examined the impact of contraceptive counseling
preconception health services, which might improve infant and among adolescents (24–29), with four finding a statistically
men’s health. The evidence base for preconception health is not significant positive impact of low-intensity (27) or moderate-
well established and is less than that for women’s preconception intensity (24,25,29) counseling interventions on at least one
health. There is a risk of over-screening if recommendations outcome of interest; study designs included two pre-post
are not followed. There is a potential risk that a client with studies (24,30), one controlled trial (29), and one RCT (27). In
a positive screen might not be able to afford treatment if the addition, five studies were identified that examined the impact
client is uninsured and not eligible for public programs. The of reminder system interventions in clinical settings on family
human and financial cost of providing preconception health planning outcomes and met the inclusion criteria (31–35); of
services might mean that fewer contraceptive and other services these, two found a statistically significant positive impact of
can be offered. reminder systems on perfect oral contraceptive compliance, a
Rationale: The potential benefits to men and infant health retrospective historical nonrandomized controlled trial that
were thought by the panel to be greater than the costs, potential examined daily reminder email messages (31) and a cohort
harms, and opportunity costs of not providing these services. study that examined use of a small reminder device that
Implementation (e.g., training and monitoring of providers) emitted a daily audible beep (34). In addition, two studies
can address the issues related to providers over-screening examined the impact of reminder systems among depot
and not following the federal and professional medical medroxyprogesterone acetate users (DMPA) (33,35) with one,
recommendations. CDC will continue to monitor related a retrospective cohort study, finding a statistically significant
research and modify these recommendations, as needed. positive impact of receiving a wallet-sized reminder card with
Health-care reform might make follow-up care more available the date of the next DMPA injection and a reminder postcard
to low-income clients. All seven EWG members agreed to this shortly before the next injection appointment on timely
recommendation. DMPA injections. Statements about safety and unnecessary
medical examinations and tests are made on the basis of CDC
guidelines on contraceptive use (36,37).
Contraceptive Services — Potential consequences: Fewer clients will use methods that
are not safe for them, there will be increased contraceptive use,
Contraceptive Counseling Steps increased use of more effective methods, increased continuation
Recommendation: To help a client who is initiating or of method use, increased use of dual methods, increased
switching to a new method of contraception, providers should knowledge, increased satisfaction with services, and increased
follow these steps, which are in accordance with the key principles use of repeat or follow-up services.
for providing quality counseling: 1) establish and maintain Rationale: Making sure that a contraceptive method is
rapport with the client; 2) obtain clinical and social information safe for an individual client is a fundamental responsibility of
from the client; 3) work with the client interactively to select the all providers of family planning services. Removing medical
most effective and appropriate contraceptive method for her or barriers to contraceptive use is key to increasing access
him; 4) provide a physical assessment related to contraceptive to contraception and helping clients prevent unintended
use, when warranted; and 5) provide the contraceptive method pregnancy. Consistent use of contraceptives is needed to prevent
along with instructions about correct and consistent use, help unintended pregnancies, so appropriate counseling is critical
the client develop a plan for using the selected method and for to ensure clients make the best possible choice of methods for
follow-up, and confirm understanding. their unique circumstances, and are supported in continued
36 MMWR / April 25, 2014 / Vol. 63 / No. 4

use of the chosen method. The principles of quality counseling, financial barriers to long-acting reversible contraception for
from which the steps listed in the recommendations are based, many persons. The potential increase in use of long-acting
are supported by a substantial body of evidence and expert reversible contraception and other more effective methods is
opinion. Future research to evaluate the five principles will be likely to help reduce rates of unintended pregnancy. All seven
monitored and the recommendations modified, as needed. All EWG members agreed to this recommendation.
seven EWG members agreed to this recommendation.
Contraceptive Services — Broad

Contraceptive Services — Tiered Range of Methods
Approach to Counseling Recommendation: A broad range of methods should be
Recommendation: For clients who might want to get available on-site or through referral.
pregnant in the future and prefer reversible methods of Quality of evidence: Three descriptive studies from the review
contraception, providers should use a tiered approach to of quality improvement literature identified contraceptive choice
presenting a broad range of contraceptive methods (including as an important aspect of quality care (42–44).
long-acting reversible contraception such as intrauterine Potential consequences: Clients will be more likely to select
devices and contraceptive implants), in which the most a method that they will use consistently and correctly.
effective methods are presented before less effective methods. Rationale: A central tenet of quality health care is that
Quality of evidence: National surveys have demonstrated it be client-centered. Being able to provide a client with
low rates of LARC use overall (38,39). However, Project a method that best fits her or his unique circumstances is
CHOICE has demonstrated high uptake of long-acting essential for that reason. All seven EWG members agreed to
reversible contraception (approximately two thirds of clients this recommendation.
when financial barriers are removed) and a very substantial
reduction in rates of unintended pregnancy (40). Further, a
recent study of postpartum contraceptive use shows that 50% Contraceptive Services — Education
of teen mothers with a recent live birth are using long-acting Recommendation: The content, format, method, and
reversible contraception postpartum in Colorado, which medium for delivering education should be evidence-based.
demonstrates high levels of acceptance in the context of a Quality of evidence: Seventeen studies were identified
statewide program to remove financial barriers (41). that met the inclusion criteria for this systematic review. Of
Potential consequences: Use of long-acting reversible these, 15 studies looked at knowledge of correct method use
contraception has the potential to help many more persons or contraceptive risks and benefits, including side effects
prevent unintended pregnancy because of its ease of use, safety, and method effectiveness (45–59). All but one study (56)
and effectiveness. Several questions were raised about ethical found a statistically significant positive impact of educational
issues in using a tiered approach to counseling. First, is it ethical interventions on increased knowledge. These studies included
to educate about long-acting reversible contraception when six randomized controlled trials with low risk for bias.
the methods are not all available on-site? Second, conversely, Potential consequences: Clients will make more informed
is it ethical not to inform clients about the most effective decisions when choosing a contraceptive method. More clients will
methods? In other health service areas, the standard of care be satisfied with the process of selecting a contraceptive method.
is to inform the client about the most effective treatment Rationale: Knowledge obtained through educational
(e.g., blood pressure medications), so the client can make a activities, as integrated into the larger counseling model, is
fully informed decision, and this standard should apply in a critically important precondition for the client’s ability to
this instance as well. On the basis of historic experiences, make informed decisions. The techniques described in the
there is a need to ensure that methods always are offered on recommendations have a well-established evidence base for
a completely voluntary and noncoercive basis. Health-care increasing knowledge and satisfaction with services. This
reform might make contraceptive services more available to knowledge lays the foundation for further counseling steps that
the majority of clients. will increase the likelihood of correct and consistent use, and
Rationale: Providers have an obligation to inform clients increased satisfaction will increase return visits to the service
about the most effective methods available, even if they cannot site, as needed. Four of seven EWG members agreed to this
provide them. Further, health-care reform will reduce the recommendation; three members did not express an opinion.
MMWR / April 25, 2014 / Vol. 63 / No. 4 37

Contraceptive Services — absence of harmful effects from comprehensive sexual health

education was noted.
Confirm Understanding Rationale: The benefits of informing adolescents about all ways
Recommendation: A check box or written statement should to prevent pregnancy are substantial. Ultimately, each adolescent
be available in the medical record that can be used to document should make an informed decision that meets her or his unique
that the client expressed understanding of the most important circumstances, based on the counseling provided by the provider.
information about her/his chosen contraceptive method. The Six of seven EWG members agreed to this recommendation.
teach-back method may be used to get clients to express the
most important points by repeating back messages about
risks and benefits and appropriate method use and follow-up. Adolescent Services — Use of Long-
Documentation of understanding using the teach-back method
and a check box or written statement can be used in place of
Acting Reversible Contraception
a written method-specific informed consent. Recommendation: Education about contraceptive methods
Quality of evidence: Two studies from outside the family should include an explanation that long-acting reversible
planning literature (one cohort study and one controlled contraception is safe and effective for nulliparous women
trial with unclear randomization) (60,61) and a strong (women who have not been pregnant or given birth), including
recommendation by members of the Technical Panel on adolescents.
Counseling and Education were considered. Quality of evidence: CDC guidelines on contraceptive use
Potential consequences: More clients will make informed (37) provide evidence that long-acting reversible contraception
decisions, adherence to contraceptive and treatment plans will is safe and effective for adolescents and nulliparous women.
improve, and reproductive and other health conditions will be Potential consequences: More providers will encourage
better controlled. adolescents to consider long-acting reversible contraception;
Rationale: Asking providers to document in the record more adolescents will choose long-acting reversible
that the client is making an informed decision will increase contraception, resulting in reduced rates of teen pregnancy,
providers’ attention to this task. This recommendation will including rapid repeat pregnancy.
replace a previous requirement that providers obtain method- Rationale: Long-acting reversible contraception is safe for
specific informed consent from each client (in addition to a adolescents (37). As noted above, providers should inform
general consent form). Six of seven EWG members agreed to clients about the most effective methods available. The
this recommendation. potential increase in use of long-acting reversible contraception
and other more effective methods by adolescents is substantial
and is likely to lead to further reductions in teen pregnancy.
Adolescent Services — Three EWG members agreed to this recommendation; two
EWG members abstained.
Comprehensive Information
Recommendation: Providers should provide comprehensive
information to adolescent clients about how to prevent Adolescent Services —
pregnancy and STDs. This should include information about
contraception and that avoiding sex (abstinence) is an effective
Confidential Services
way to prevent pregnancy and STDs. Recommendation: Confidential family planning services
Quality of evidence: A systematic review was not conducted should be made available to adolescents, while observing state
because other recent reviews were available that have shown a laws and any legal obligations for reporting.
substantial impact of comprehensive sexual health education Quality of evidence: Six descriptive studies documented
on reduced adolescent risk behavior (62–66). The evidence for one or more of the following: that confidentiality is important
abstinence-only education was more limited: CDC’s Community to adolescents; that many adolescents reported they will not
Guide concluded that there was insufficient evidence (67), but use reproductive health services if confidentiality cannot be
the Department of Health and Human Services’ Office of assured; and that adolescents might not be honest in discussing
Adolescent Health has identified two abstinence-based programs reproductive health with providers if confidentiality cannot be
as having evidence of effectiveness (68). assured (69–74). One RCT showed a slight reduction in use of
Potential consequences: Teens will make more informed services after receiving conditional confidentiality, compared
decisions and will delay initiation of sexual intercourse. The with complete confidentiality (75). One study showed a
38 MMWR / April 25, 2014 / Vol. 63 / No. 4

positive association between confidentiality and intention to Adolescent Services —

use services (73).
Potential consequences: Consequences might include an Repeat Teen Pregnancy
increased intention to use services, increased use of services, and Recommendation: Providers should refer pregnant and
reduced rates of teen pregnancy. However, explaining the need parenting adolescents to home visiting and other programs
to report under certain circumstances (rape, child abuse) might that have been shown to provide needed support and reduce
deter some adolescent clients from using services. Further, some rates of repeat teen pregnancy.
parents/guardians might not agree that adolescents should have Quality of evidence: Three of four studies of clinic-based
access to confidential services. programs (using retrospective case-control cohort, ecological
Rationale: Minors’ rights to confidential reproductive health evaluation, and prospective cohort study designs) showed that
services are consistent with state and federal law. The risks of comprehensive teen pregnancy prevention programs (programs
not providing confidential services to adolescents are great and with clinical, school, case management, and community
likely to result in an increased rate of teen pregnancies. Finally, components) were associated with both medium- and long-
this recommendation is consistent with the recommendations term outcomes (95–98). In addition, several randomized trials
of three professional medical associations that endorse of community-based home visiting programs, and an existing
provision of confidential services to adolescents (76–78). All systematic review of the home visiting literature, demonstrated
seven EWG members agreed to this recommendation. a protective impact of these programs on preventing repeat teen
pregnancy and other relevant outcomes (99–103).
Potential consequences: Consequences might include
Adolescent Services — decreased rapid repeat pregnancy and abortion rates, and
increased use of contraceptives.
Family-Child Communication Rationale: There is sufficient evidence to recommend that
Recommendation: Providers should encourage and promote providers link pregnant and parenting teens to community and
family-child communication about sexual and reproductive health. social services that might reduce rates of rapid repeat pregnancy.
Quality of evidence: From the family planning literature, Three of seven EWG members agreed to an earlier version of
16 parental involvement programs (most using an RCT study this recommendation. Other members wanted to remove a
design) were found to be positively associated with at least one clause about prioritizing the contraceptive needs of pregnant/
short-term (13 of 16 studies) or medium-term (four of seven parenting teens because they felt that all clients should be
studies) outcome (79–94). However, only one of these studies treated as priority clients. This suggestion was adopted, but
was linked to clinical services (80); others were implemented the EWG did not have a chance to vote again on the modified
in community settings. recommendation.
increased parental/guardian involvement and communication,
improved knowledge/awareness, increased intentions to use Contraceptive Method Availability
contraceptives, and the adoption of more pro-social norms
Recommendation: Family planning programs should stock
that support parent-child communication about sexual health.
and offer a broad a range of FDA-approved contraceptive
Rationale: The literature provides strong evidence that
methods so that the needs of individual clients can be met.
increased communication between a child and her/his parent/
These methods are optimally available on-site, but strong
guardian will lead to safer sexual behavior among teens,
referrals can serve to make methods not available on-site real
and numerous community-based programs have created an
options for clients.
evidence base for how to strengthen parents/guardians’ ability
Quality of evidence: No research was identified that
to hold those conversations. Although less is known about
explicitly addressed the question of whether having a broad
how to do so in a clinical setting, providers can refer their
range of methods was associated with short-, medium-, or
clients to programs in the community, and principles from the
long-term reproductive health outcomes. However, as noted
community-based approaches can be used to help providers
above, three descriptive studies from the review of quality
develop appropriate approaches in the clinical setting. Research
improvement literature identified contraceptive choice as an
in this area will be monitored, and the recommendations will be
important aspect of quality care (42–44).
revised, as needed. Four of five EWG members who provided
input agreed to this recommendation; one member abstained.
increased use of contraception and increased use of reproductive
MMWR / April 25, 2014 / Vol. 63 / No. 4 39

health services. It also was noted that there are sometimes high example of comprehensively client-centered care, rather than
costs to stocking certain methods (e.g., intrauterine devices an end of its own.
and contraceptive implants).
Rationale: Having a broad range of contraceptive methods is
central to client-centered care, a core aspect of providing quality Quality Improvement
services. Individual clients need to have a choice so they can Recommendation: Family planning programs should have
select a method that best fits their particular circumstances. a system for quality improvement, which is designed to review
This is likely to result in more correct and consistent use of and strengthen the quality of services on an ongoing basis.
the chosen methods. The benefits of this recommendation Family planning programs should select, measure, and assess
were weighed more heavily than the negative outcomes at least one outcome measure on an ongoing basis, for which
(e.g., additional cost). All five EWG members agreed to this the service site can be accountable.
recommendation. Quality of evidence: A recent systematic review (122) was
supplemented with 10 articles that provided information related
to client and/or provider perspectives regarding what constitutes
Youth-Friendly Services quality family planning services (42–44,113,123–128). These
Recommendation: Family planning programs should take studies used a qualitative (k = 4) or cross-sectional (k = 6) study
steps to make services “youth-friendly.” design. Ten descriptive studies identified client and provider
Quality of evidence: Of 20 studies that were identified, perspectives on what constitutes quality family planning services,
six looked at short-, medium-, or long-term outcomes with which include stigma and embarrassment reduction (n = 9), client
mixed designs (one group time series, one cross-sectional, three access and convenience (n = 8); confidentiality (n = 3); efficiency
prospective cohort, and one nonrandomized trial); protective and tailoring of services (n = 6); client autonomy and confidence
effects were found on long-term (two of three studies), (n = 5); contraceptive access and choice (n = 4); increased time
medium-term (three of three), and short-term (three of three) of patient-provider interaction (n = 3); communication and
outcomes (29,30,104–107). One of these six studies (29), plus relationship (n = 3); structure and facilities (n = 2); continuity
13 other descriptive studies (for a total of 14 studies), presented of care (n = 2). Well-established frameworks for guiding quality
adolescents’ or providers’ views on facilitators for adolescent improvement efforts were referenced (122,129–132).
clients in using youth-friendly family planning services. Key Potential consequences: Consequences might include
factors described were confidentiality (13 of 14), accessibility increased use by clients of more effective contraceptive methods,
(11 of 14), peer involvement (three of 14), parental or familial clients might be more likely to return for care, client satisfaction
involvement (four of 14), and quality of provider interaction might improve, and there might be reduced rates of teen and
(11 of 14) (105–121). Four of these studies (111,112,114,121) unintended pregnancy, and improved spacing of births.
plus one other descriptive study (108) described barriers to Rationale: Research, albeit limited, has demonstrated that
clinics adopting and implementing youth-friendly family quality services are associated with improved client experience
planning services. with care and adoption of more protective contraceptive
Potential consequences: Consequences might include behavior. Further, these recommendations on quality
increased use of reproductive health services by adolescents, improvement are consistent with those made by national leaders
improved contraceptive use, use of more effective methods, in the quality improvement field. Research is either under way
more consistent use of contraception, and reduced rates of teen or planned to validate a core set of performance measures, and
pregnancy. It is also likely to lead to improved satisfaction with the recommendations will be updated as new findings emerge.
services and greater knowledge about pregnancy prevention All five EWG members agreed to these recommendations.
among adolescents. It is possible that there will be higher costs,
References
and some uncertainty regarding the benefits due to a relatively
weak evidence base. 1. Family Planning Services and Population Research Act of 1970, Title
X. Population Research and Voluntary Family Planning Programs
Rationale: Existing evidence has demonstrated the
Project Grants and Contracts for Family Planning Services Pub. L. No.
importance of specific characteristics to adolescents’ attitudes Public Law 91-572 (1970).
and use of clinical services. The potential benefits of providing 2. Project Grants for Family Planning Services. 42 CFR Part 59, Subpart A,
youth-friendly services outweigh the potential costs and (1971).
weak evidence base. All five EWG members agreed to this 3. CDC. Recommendations to improve preconception health and health
recommendation. Some thought that it should be cast as an care—United States. MMWR 2006;55(No. RR-06).
40 MMWR / April 25, 2014 / Vol. 63 / No. 4

4. CDC. Sexually transmitted diseases treatment guidelines, 2010. 25. Brindis CD, Geierstanger SP, Wilcox N, McCarter V, Hubbard A.
MMWR 2010;59(No. RR-12). Evaluation of a peer provider reproductive health service model for
5. CDC. Revised recommendations for HIV testing of adults, adolescents and adolescents. Perspect Sex Reprod Health 2005;37:85–91.
pregnant women in health care settings. MMWR 2006;55(No. RR-14). 26. Cowley CB, Farley T, Beamis K. ‘Well, maybe I’ll try the pill for just
6. Jack B, Atrash H, Coonrod D, Moos M, O’Donnell J, Johnson K. The a few months...’: Brief motivational and narrative-based interventions
clinical content of preconception care: an overview and preparation of this to encourage contraceptive use among adolescents at high risk for early
supplement. Am J Obstet Gynecol 2008;199(Supplement B):S266–79. childbearing. Fam Syst Health 2002;20:183–204.
7. Frey K, Navarro S, Kotelchuck M, Lu M. The clinical content of 27. Hanna KM. Effect of nurse-client transaction on female adolescents’
preconception care: preconception care for men. Am J Obstet Gynecol oral contraceptive adherence. Image J Nurs Sch 1993;25:285–90.
2008;199(6 Suppl 2):S389–95. 28. Kirby D, Raine T, Thrush G, Yuen C, Sokoloff A, Potter SC. Impact
8. Adams-Skinner J, Exner T, Pili C, Wallace B, Hoffman S, Leu CS. The of an intervention to improve contraceptive use through follow-up
development and validation of a tool to assess nurse performance in phone calls to female adolescent clinic patients. Perspect Sex Reprod
dual protection counseling. Patient Educ Couns 2009;76:265–71. Health 2010;42:251–7.
9. Bender SS, Geirsson RT. Effectiveness of preabortion counseling on 29. Winter L, Breckenmaker LC. Tailoring family planning services to the
postabortion contraceptive use. Contraception 2004;69:481–7. special needs of adolescents. Fam Plann Perspect 1991;23:24–30.
10. Boise R, Petersen R, Curtis KM, et al. Reproductive health counseling 30. Brindis CD, Geierstanger SP, Wilcox N, McCarter V, Hubbard A.
at pregnancy testing: a pilot study. Contraception 2003;68:377–83. Evaluation of a peer provider reproductive health service model for
11. Custo G, Saitto C, Cerza S, Sertoli G. The adjusted contraceptive score adolescents. Perspect Sex Reprod Health 2005;37:85–91.
(ACS) improves the overall performance of behavioural and barrier 31. Fox MC, Creinin MD, Murthy AS, Harwood B, Reid LM. Feasibility
contraceptive methods. Adv Contracept Deliv Syst 1987;3:367–73. study of the use of a daily electronic mail reminder to improve oral
12. Gilliam M, Knight S, McCarthy M Jr. Success with oral contraceptives: contraceptive compliance. Contraception 2003;68:365–71.
a pilot study. Contraception 2004;69:413–8. 32. Hou MY, Hurwitz S, Kavanagh E, Fortin J, Goldberg AB. Using daily
13. Langston AM, Rosario L, Westhoff CL. Structured contraceptive text-message reminders to improve adherence with oral contraceptives:
counseling—a randomized controlled trial. Patient Educ Couns a randomized controlled trial. Obstet Gynecol 2010;116:633–40.
2010;81:362–7. 33. Keder LM, Rulin MC, Gruss J. Compliance with depot
14. Lee JK, Parisi SM, Akers AY, Borrero S, Schwarz EB. The impact of medroxyprogesterone acetate: a randomized, controlled trial of intensive
contraceptive counseling in primary care on contraceptive use. J Gen reminders. Am J Obstet Gynecol 1998;179:583–5.
Intern Med 2011;26:731–6. 34. Lachowsky M, Levy-Toledano R. Improving compliance in oral
15. Namerow PB, Weatherby N, Williams-Kaye J. The effectiveness of contraception: ‘the reminder card’. Eur J Contracept Reprod Health
contingency-planning counseling. Fam Plann Perspect 1989;21:115–9. Care 2002;7:210–5.
16. Nobili MP, Piergrossi S, Brusati V, Moja EA. The effect of patient- 35. Madlon-Kay DJ. The effectiveness of a mail reminder system for depot
centered contraceptive counseling in women who undergo a voluntary medroxyprogesterone injections. Arch Fam Med 1996;5:234–6.
termination of pregnancy. Patient Educ Couns 2007;65:361–8. 36. CDC. U.S. selected practice recommendations for contraceptive use
17. Petersen R, Albright J, Garrett JM, Curtis KM. Pregnancy and STD 2013. MMWR 2013;62(No. RR-4).
prevention counseling using an adaptation of motivational interviewing: a 37. CDC. U.S. medical eligibility criteria for contraceptive use 2010.
randomized controlled trial. Perspect Sex Reprod Health 2007;39:21–8. MMWR 2010;59(No. RR-4).
18. Proctor A, Jenkins TR, Loeb T, Elliot M, Ryan A. Patient satisfaction 38. Daniels K, Mosher W, Jones J. Contraceptive methods women have ever
with 3 methods of postpartum contraceptive counseling: a randomized, used: United States, 1982–2010. National health statistics reports; 2013;62.
prospective trial. J Reprod Med 2006;51:377–82. 39. Martinez G, Copen C, Abma J. Teenagers in the United States: sexual
19. Schunmann C, Glasier A. Specialist contraceptive counselling and activity, contraceptive use, and childbearing, 2006–2010 National
provision after termination of pregnancy improves uptake of long-acting Survey of Family Growth. Vital Health Stat 2011;23(31).
methods but does not prevent repeat abortion: a randomized trial. 40. Winner B, Peipert J, Zhao Q, et al. Effectiveness of long-acting
Hum Reprod 2006;21:2296–303. reversible contraception. N Engl J Med 2012;366:1998–2007.
20. Shlay JC, Mayhugh B, Foster M, Maravi ME, Baron AE, Douglas JM 41. CDC. Vital signs: repeat births among teens—United States, 2007–2010.
Jr. Initiating contraception in sexually transmitted disease clinic setting: MMWR 2013;62:249–55.
a randomized trial. Am J Obstet Gynecol 2003;189:473–81. 42. Becker D, Klassen AC, Koenig MA, LaVeist TA, Sonenstein FL, Tsui
21. Todres R. Effectiveness of counseling in the transmission of family AO. Women’s perspectives on family planning service quality: an
planning and sexuality knowledge. J Sex Educ Ther 1990;16:279–85. exploration of differences by race, ethnicity and language. Perspect Sex
22. Weisman CS, Maccannon DS, Henderson JT, Shortridge E, Orso CL. Reprod Health 2009;41:158–65.
Contraceptive counseling in managed care: preventing unintended 43. Gilliam ML, Hernandez M. Providing contraceptive care to low-
pregnancy in adults. Womens Health Issues 2002;12:79–95. income, African American teens: the experience of urban community
23. Yassin AS, Cordwell D. Does dedicated pre-abortion contraception health centers. J Community Health 2007;32:231–44.
counselling help to improve post-abortion contraception uptake? J Fam 44. Landry DJ, Wei J, Frost JJ. Public and private providers’ involvement
Plann Reprod Health Care 2005;31:115–6. in improving their patients’ contraceptive use. Contraception
24. Berger DK, Perez G, Kyman W, et al. Influence of family planning 2008;78:42–51.
counseling in an adolescent clinic on sexual activity and contraceptive 45. Deijen JB, Kornaat H. The influence of type of information,
use. J Adolesc Health Care 1987;8:436–40. somatization, and locus of control on attitude, knowledge, and
compliance with respect to the triphasic oral contraceptive Tri-Minulet.
Contraception 1997;56:31–41.
MMWR / April 25, 2014 / Vol. 63 / No. 4 41

46. Kirby D, Harvey PD, Claussenius D, Novar M. A direct mailing to 64. Kirby D, Obasi A, Laris BA. The effectiveness of sex education and
teenage males about condom use: its impact on knowledge, attitudes HIV education interventions in schools in developing countries. World
and sexual behavior. Fam Plann Perspect 1989;21:12–8. Health Organ Tech Rep Ser 2006;938:103–50, discussion 317–41.
47. Little P, Griffin S, Kelly J, Dickson N, Sadler C. Effect of educational 65. Kirby DB, Laris BA, Rolleri LA. Sex and HIV education programs:
leaflets and questions on knowledge of contraception in women taking their impact on sexual behaviors of young people throughout the world.
the combined contraceptive pill: randomised controlled trial. BMJ J Adolesc Health 2007;40:206–17.
1998;316:1948–52. 66. Oringanje C, Meremikwu MM, Eko H, Esu E, Meremikwu A, Ehiri
48. Smith LF, Whitfield MJ. Women’s knowledge of taking oral contraceptive JE. Interventions for preventing unintended pregnancies among
pills correctly and of emergency contraception: effect of providing adolescents. Cochrane Database Syst Rev 2009;(4):CD005215.
information leaflets in general practice. Br J Gen Pract 1995;45:409–14. 67. Guide to Community Preventive Services. Preventing HIV/AIDS,
49. Steiner MJ, Dalebout S, Condon S, Dominik R, Trussell J. other STIs, and teen pregnancy: group-based abstinence education
Understanding risk: a randomized controlled trial of communicating interventions for adolescents. Atlanta, GA: US Department of Health
contraceptive effectiveness. Obstet Gynecol 2003;102:709–17. and Human Services, CDC; 2009; Available at http://www.
50. DeLamater J, Wagstaff DA, Havens KK. The impact of a culturally thecommunityguide.org/hiv/abstinence_ed.html.
appropriate STD/AIDS education intervention on black male 68. Office of Adolescent Health. Information about effective programs for
adolescents’ sexual and condom use behavior. Health Educ Behav preventing teen pregnancy. Washington, DC: US Department of Health
2000;27:454–70. and Human Services; 2011. Available at www.hhs.gov/ash/oah/oah-
51. Mason V, McEwan A, Walker D, Barrett S, James D. The use of video initiatives/tpp/programs.html.
information in obtaining consent for female sterilisation: a randomised 69. Ford CA, Thomsen SL, Compton B. Adolescents’ interpretations of
study. BJOG 2003;110:1062–71. conditional confidentiality assurances. J Adolesc Health 2001;29:156–9.
52. Schwarz EB, Gerbert B, Gonzales R. Computer-assisted provision of 70. Garside R, Ayres R, Owen M, Pearson VA, Roizen J. Anonymity and
emergency contraception a randomized controlled trial. J Gen Intern confidentiality: rural teenagers’ concerns when accessing sexual health
Med 2008;23:794–9. services. J Fam Plann Reprod Health Care 2002;28:23–6.
53. Paperny DM, Starn JR. Adolescent pregnancy prevention by health 71. Rainey DY, Brandon DP, Krowchuk DP. Confidential billing accounts
education computer games: computer-assisted instruction of knowledge for adolescents in private practice. J Adolesc Health 2000;26:389–91.
and attitudes. Pediatrics 1989;83:742–52. 72. Schuster MA, Bell RM, Petersen LP, Kanouse DE. Communication
54. Reis J, Tymchyshyn P. A longitudinal evaluation of computer-assisted between adolescents and physicians about sexual behavior and risk
instruction on contraception for college students. Adolescence prevention. Arch Pediatr Adolesc Med 1996;150:906–13.
1992;27:803–11. 73. Thomas N, Murray E, Rogstad KE. Confidentiality is essential if young
55. Roberto AJ, Zimmerman RS, Carlyle KE, Abner EL, Cupp PK, Hansen people are to access sexual health services. Int J STD AIDS
GL. The effects of a computer-based pregnancy, STD, and HIV 2006;17:525–9.
prevention intervention: a nine-school trial. Health Commun 74. Thrall JS, McCloskey L, Ettner SL, Rothman E, Tighe JE, Emans SJ.
2007;21:115–24. Confidentiality and adolescents’ use of providers for health information and
56. Lindenberg CS, Solorzano RM, Bear D, Strickland O, Galvis C, for pelvic examinations. Arch Pediatr Adolesc Med 2000;154:885–92.
Pittman K. Reducing substance use and risky sexual behavior among 75. Ford CAMS, Halpern-Felsher BL, Irwin CE Jr. Influence of physician
young, low-income, Mexican-American women: comparison of two confidentiality assurances on adolescents’ willingness to disclose
interventions. Appl Nurs Res 2002;15:137–48. information and seek future health care. A randomized controlled trial.
57. Chewning B, Mosena P, Wilson D, et al. Evaluation of a computerized JAMA 1997;278:1029–34.
contraceptive decision aid for adolescent patients. Patient Educ Couns 76. American College of Obstetricians and Gynecologists. Confidentiality
1999;38:227–39. in adolescent health care: guidelines for adolescent health care. 2nd
58. O’Donnell L, San Doval A, Duran R, O’Donnell CR. The effectiveness ed. Washington, DC: American College of Obstetricians and
of video-based interventions in promoting condom acquisition among Gynecologists; 2011.
STD clinic patients. Sex Transm Dis 1995;22:97–103. 77. American Academy of Pediatrics. Achieving quality health services for
59. Pedrazzini AE, McGowan H, Lucking L, Johanson RJ. ‘The trouble adolescents: policy statement of the Committee on Adolescence,
with sex–it always gets in the way’: an evaluation of a peer-produced American Academy of Pediatrics. Pediatrics 2008;121:1263.
teenage pregnancy video. Br J Fam Plann 2000;26:131–5. 78. Ford C, English A, Sigman G. Confidential health care for adolescents:
60. McMahon SR, Rimsza ME, Bay RC. Parents can dose liquid medication position paper for the society for adolescent medicine. J Adolesc Health
accurately. Pediatrics 1997;100:330–3. 2004;35:160–7.
61. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician 79. Anderson NLR, Koniak-Griffin D, Keenan CK, Uman G, Duggal BR,
communication with diabetic patients who have low health literacy. Casey C. Evaluating the outcomes of parent-child family life education
Arch Intern Med 2003;163:83–90. [including commentary by Hayman LL]. Sch Inq Nurs Pract
62. Kirby D. Comprehensive sex education: strong public support and 1999;13:211–38.
persuasive evidence of impact, but little funding. Arch Pediatr Adolesc 80. Guilamo-Ramos V, Bouris A, Jaccard J, Gonzalez B, McCoy W, Aranda
Med 2006;160:1182–4. D. A parent-based intervention to reduce sexual risk behavior in early
63. Guide to Community Preventive Services. Preventing HIV/AIDS, adolescence: building alliances between physicians, social workers, and
other STIs, and teen pregnancy: group-based comprehensive risk parents. J Adolesc Health;48:159–63.
reduction interventions for adolescents. Atlanta, GA: US Department 81. Blake SM, Simkin L, Ledsky R, Perkins C, Calabrese JM. Effects of a
of Health and Human Services, CDC; 2009. Available at http://www. parent-child communications intervention on young adolescents’ risk for
thecommunityguide.org/hiv/riskreduction.html. early onset of sexual intercourse. Fam Plann Perspect 2001;33:52–61.
42 MMWR / April 25, 2014 / Vol. 63 / No. 4

82. Brody GH, Murry VM, Gerrard M, et al. The Strong African American 100. Olds D, Henderson CR Jr, Cole R, et al. Long-term effects of nurse
Families Program: translating research into prevention programming. home visitation on children’s criminal and antisocial behavior: 15-year
Child Dev 2004;75:900–17. follow-up of a randomized controlled trial. JAMA 1998;280:1238–44.
83. Evans WD, Davis KC, Ashley OS, Blitstein J, Koo H, Zhang Y. Efficacy 101. Olds DL, Eckenrode J, Henderson CR Jr, et al. Long-term effects of home
of abstinence promotion media messages: findings from an online visitation on maternal life course and child abuse and neglect. Fifteen-year
randomized trial. J Adolesc Health 2009;45:409–16. follow-up of a randomized trial. JAMA 1997;278:637–43.
84. Forehand R, Armistead L, Long N, et al. Efficacy of a parent-based sexual- 102. Black M, Bentley M, Papas M, et al. Delaying second births among
risk prevention program for African American preadolescents: a randomized adolescent mothers: a randomized, controlled trial of a home-based
controlled trial. Arch Pediatr Adolesc Med 2007;161:1123–9. mentoring program. Pediatrics 2006;118:1087–99.
85. Haggerty KP, Skinner ML, MacKenzie EP, Catalano RF. A randomized 103. Avellar S, Paulsell D, Sama-Miller E, Del Grosso P. Home visiting
trial of Parents Who Care: effects on key outcomes at 24-month evidence of effectiveness review. Washington, DC: US Department of
follow-up. Prev Sci 2007;8:249–60. Health and Human Services, Office of Planning, Research and
86. Huston RL, Martin LJ, Foulds DM. Effect of a program to facilitate Evaluation, Administration for Children and Families; 2012.
parent-child communication about sex. Clin Pediatr (Phila) 104. Wilson S, Daniel S, Pearson J, Hopton C, Madeley R. An evaluation
1990;29:626–33. of a new teenage clinic and its impact on teenage conceptions in
87. Lederman RP, Chan W, Roberts-Gray C. Sexual risk attitudes and Nottingham from 1986 to 1992. Contraception 1994;50:77–86.
intentions of youth aged 12–14 years: survey comparisons of parent- 105. Gupta S, Hogan R, Kirkman RJ. Experience of the first pelvic
teen prevention and control groups. Behavioral Medicine (Washington, examination. Eur J Contracept Reprod Health Care 2001;6:34–8.
DC) 2004;29:155–63. 106. Morrison A, Mackie CM, Elliott L, Elliott LM, Gruer L, Bigrigg A.
88. Lederman RP, Chan W, Roberts-Gray C. Parent-adolescent relationship The Sexual Health Help Centre: a service for young people. J Public
education (PARE): program delivery to reduce risks for adolescent Health Med 1997;19:457–63.
pregnancy and STDs. Behav Med 2008;33:137–43. 107. Herz EJ, Olson LM, Reis JS. Family planning for teens: strategies for
89. Lefkowitz ES, Sigman M, Au TK. Helping mothers discuss sexuality improving outreach and service delivery in public health settings. Public
and AIDS with adolescents. Child Dev 2000;71:1383–94. Health Rep 1988;103:422–30.
90. Miller BC, Norton MC, Jenson GO. Impact Evaluation of Facts and 108. Bethea J, Hippisley-Cox J, Coupland C, Pringle M. General practitioners’
Feelings: a home-based video sex education curriculum. Fam Relat attitudes towards the provision of services to young people aged under
1993;42:392–400. 16: a cross-sectional survey. Qual Prim Care 2007;15:11–9.
91. Murry VM, Berkel C, Brody GH, Gerrard M, Gibbons FX. The Strong 109. Kapphahn CJ, Wilson KM, Klein JD. Adolescent girls’ and boys’
African American Families program: longitudinal pathways to sexual preferences for provider gender and confidentiality in their health care.
risk reduction. J Adolesc Health 2007;41:333–42. J Adolesc Health 1999;25:131–42.
92. Schuster MA, Corona R, Elliott MN, et al. Evaluation of Talking 110. Wilson A, Williams R. Sexual health services: what do teenagers want?
Parents, Healthy Teens, a new worksite based parenting programme to Ambul Child Health 2000;6:253–60.
promote parent-adolescent communication about sexual health: 111. Alberti PM, Steinberg AB, Hadi EK, Abdullah RB, Bedell JF. Barriers
randomised controlled trial. BMJ 2008;337:a308. at the frontline: assessing and improving the teen friendliness of South
93. Stanton B, Cole M, Galbraith J, et al. Randomized trial of a parent Bronx medical practices. Public Health Rep 2010;125:611–4.
intervention: parents can make a difference in long-term adolescent 112. Brindis CD, Loo VS, Adler NE, Bolan GA, Wasserheit JN. Service
risk behaviors, perceptions, and knowledge. Arch Pediatr Adolesc Med integration and teen friendliness in practice: a program assessment of
2004;158:947–55. sexual and reproductive health services for adolescents. J Adolesc Health
94. Stanton BF, Li X, Galbraith J, et al. Parental underestimates of 2005;37:155–62.
adolescent risk behavior: a randomized, controlled trial of a parental 113. Chambers R, Boath E, Chambers S. Young people’s and professionals’
monitoring intervention. J Adolesc Health 2000;26:18–26. views about ways to reduce teenage pregnancy rates: to agree or not
95. Elster AB, Lamb ME, Tavare J, Ralston CW. The medical and agree. J Fam Plann Reprod Health Care 2002;28:85–90.
psychosocial impact of comprehensive care on adolescent pregnancy 114. Cromer BA, McCarthy M. Family planning services in adolescent
and parenthood. JAMA 1987;258:1187–92. pregnancy prevention: the views of key informants in four countries.
96. Omar HA, Fowler A, McClanahan KK. Significant reduction of repeat Fam Plann Perspect 1999;31:287–93.
teen pregnancy in a comprehensive young parent program. J Pediatr 115. Donovan C, Mellanby AR, Jacobson LD, Taylor B, Tripp JH; The
Adolesc Gynecol 2008;21:283–7. Adolescent Working Group. Teenagers’ views on the general practice
97. Rabin JM, Seltzer V, Pollack S. The long term benefits of a consultation and provision of contraception. Br J Gen Pract
comprehensive teenage pregnancy program. Clin Pediatr (Phila) 1997;47:715–8.
1991;30:305–9. 116. French RS. The experience of young people with contraceptive
98. Stevens-Simon C, Kelly L, Kulick R. A village would be nice but...it consultations and health care workers. Int J Adolesc Med Health
takes a long-acting contraceptive to prevent repeat adolescent 2002;14:131–8.
pregnancies. Am J Prev Med 2001;21:60–5. 117. Hayter M. Reaching marginalized young people through sexual health
99. Eckenrode J, Campa M, Luckey DW, et al. Long-term effects of prenatal nursing outreach clinics: evaluating service use and the views of service
and infancy nurse home visitation on the life course of youths: 19-year users. Public Health Nurs 2005;22:339–46.
follow-up of a randomized trial. Arch Pediatr Adolesc Med 118. Ingram J, Salmon D. ‘No worries!’ Young people’s experiences of nurse-
2010;164:9–15. led drop-in sexual health services in South West England. J Res Nurs
2007;12:305–16.
MMWR / April 25, 2014 / Vol. 63 / No. 4 43

119. Peremans L, Hermann I, Avonts D, Van Royen P, Denekens J. 126. Dixon-Woods M, Stokes T, Young B, Phelps K, Windridge K, Shukla
Contraceptive knowledge and expectations by adolescents: an R. Choosing and using services for sexual health: a qualitative study of
explanation by focus groups. Patient Educ Couns 2000;40:133–41. women’s views. Sex Transm Infect 2001;77:335–9.
120. Perry C, Thurston M. Meeting the sexual health care needs of young 127. Khan NS, Kirkman R. Intimate examinations: use of chaperones in
people: a model that works? Child Care Health Dev 2008;34:98–103. community-based family planning clinics. BJOG 2000;107:130–2.
121. Russell ST, Lee FCH. Practitioners’ perspectives on effective practices 128. Fiddes P, Scott A, Fletcher J, Glasier A. Attitudes towards pelvic
for Hispanic teenage pregnancy prevention. Perspect Sex Reprod Health examination and chaperones: a questionnaire survey of patients and
2004;36:142–9. providers. Contraception 2003;67:313–7.
122. Becker D, Koenig MA, Kim YM, Cardona K, Sonenstein FL. The 129. Bruce J. Fundamental elements of the quality of care: a simple
quality of family planning services in the United States: findings from framework. Stud Fam Plann 1990;21:61–91.
a literature review. Perspect Sex Reprod Health 2007;39:206–15. 130. Donabedian A. The quality of care. JAMA 1988;260:1743–8.
123. Becker D, Tsui AO. Reproductive health service preferences and perceptions 131. Institute of Medicine. Crossing the quality chasm: a new health system for
of quality among low-income women: racial, ethnic and language group the 21st century. Washington, DC: National Academies of Science; 2001.
differences. Perspect Sex Reprod Health 2008;40:202–11. 132. National Quality Forum. ABCs of measurement. Washington, DC:
124. Becker H, Stuifbergen A, Tinkle M. Reproductive health care National Quality Forum; 2011. Available at http://www.qualityforum.
experiences of women with physical disabilities: a qualitative study. org/Measuring_Performance/ABCs_of_Measurement.aspx.
Arch Phys Med Rehabil 1997;78:S26–33.
125. Bender SS. Attitudes of Icelandic young people toward sexual and
reproductive health services. Fam Plann Perspect 1999;31:294–301.
44 MMWR / April 25, 2014 / Vol. 63 / No. 4

Appendix C
Principles for Providing Quality Counseling
Counseling is a process that enables clients to make use of contraceptives, and increased use of more effective
and follow through on decisions. Education is an integral methods (2,7,8). Contraceptive counseling studies that have
component of the counseling process that helps clients to personalized discussions to meet the individual needs of
make informed decisions. Providing quality counseling is an clients have been associated with increased contraceptive use,
essential component of client-centered care. increased correct use of contraceptives, increased use of more
Key principles of providing quality counseling are listed below effective methods, increased use of dual-method contraceptives
and may be used when providing family planning services. The to prevent both sexually transmitted diseases (STDs) and
model was developed in consultation with the Technical Panel pregnancy, increased quality and satisfaction with services,
on Contraceptive Counseling and Education and reviewed by increased knowledge, and enhanced psychosocial determinants
the Expert Work Group. Although developed specifically for of contraceptive use (4,7,9–12).
providing contraceptive counseling, the principles are broad and
can be applied to health counseling on other topics. Although Principle 3. Work with the Client
the principles are listed here in a particular sequence, counseling
is an iterative process, and at every point in the client encounter
Interactively to Establish a Plan
it is necessary to determine whether it is important to readdress Working with a client interactively to establish a plan,
and emphasize a given principle. including a plan for follow-up, is important. Establishing a
plan should include setting goals, discussing possible difficulties
with achieving goals, and developing action plans to deal with
Principles of Quality Counseling potential difficulties. The amount of time spent establishing a
plan will differ depending on the client’s purpose for the visit
Principle 1. Establish and Maintain and health-care needs. A client plan that requires behavioral
Rapport with the Client change should be made on the basis of the client’s own goals,
interests, and readiness for change (13–15). Use of computerized
Establishing and maintaining rapport with a client is vital
decision aids before the appointment can facilitate this process
to the encounter and achieving positive outcomes (1). This
by providing a structured yet interactive framework for
can begin by creating a welcoming environment and should
clients to analyze their available options systematically and to
continue through every stage of the client encounter, including
consider the personal importance of perceived advantages and
follow-up. The contraceptive counseling literature indicates
disadvantages (16,17). The contraceptive counseling literature
that counseling models that emphasized the quality of the
indicates that counseling models that incorporated goal
interaction between client and provider have been associated
setting and development of action plans have been associated
with decreased teen pregnancy, increased contraceptive use,
with increased contraceptive use, increased correct use of
increased use of more effective methods, increased use of repeat
contraceptives, increased use of more effective methods, and
or follow-up services, increased knowledge, and enhanced
increased knowledge (2,9,18–20). Furthermore, contraceptive
psychosocial determinants of contraceptive use (2–5) .
counseling models that incorporated follow-up contacts
resulted in decreased teen pregnancy, increased contraceptive
Principle 2. Assess the Client’s Needs and use, increased correct use of contraceptives, increased use of
Personalize Discussions Accordingly more effective methods, increased continuation of method
Each visit should be tailored to the client’s individual use, increased use of dual-method contraceptives to prevent
circumstances and needs. Clients come to family planning both STDs and pregnancy, increased use of repeat or follow-up
providers for various services and with varying needs. services, increased knowledge, and enhanced psychosocial
Standardized questions and assessment tools can help providers determinants of contraceptive use (2,3,7,11,21,22) . From the
determine what services are most appropriate for a given visit family planning education literature, computerized decision
(6). Contraceptive counseling studies that have incorporated aids have helped clients formulate questions and have been
standardized assessment tools during the counseling process associated with increased knowledge, selection of more effective
have resulted in increased contraceptive use, increased correct methods, and increased continuation and compliance (23–25).
MMWR / April 25, 2014 / Vol. 63 / No. 4 45

Principle 4. Provide Information That Can 9. Hanna KM. Effect of nurse-client transaction on female adolescents’
oral contraceptive adherence. Image J Nurs Sch 1993;25:285–90.
Be Understood and Retained by the Client 10. Schunmann C, Glasier A. Specialist contraceptive counselling and
provision after termination of pregnancy improves uptake of long-acting
Clients need information that is medically accurate, methods but does not prevent repeat abortion: a randomized trial. Hum
balanced, and nonjudgmental to make informed decisions and Reprod 2006;21:2296–303.
follow through on developed plans. When speaking with clients 11. Shlay JC, Mayhugh B, Foster M, Maravi ME, Baron AE, Douglas JM
Jr. Initiating contraception in sexually transmitted disease clinic setting:
or providing educational materials through any medium (e.g., a randomized trial. Am J Obstet Gynecol 2003;189:473–81.
written, audio/visual, or computer/web-based), the provider 12. Weisman CS, Maccannon DS, Henderson JT, Shortridge E, Orso CL.
must present information in a manner that can be readily Contraceptive counseling in managed care: preventing unintended
pregnancy in adults. Womens Health Issues 2002;12:79–95.
understood and retained by the client. Strategies for making 13. Kaplan D. Family Counseling for all counselors. Greensboro, NC: CAPS
information accessible to clients are provided (see Appendix D). Publications; 2003.
14. Nupponen R. What is counseling all about—basics in the counseling
of health-related physical activity. Patient Educ Couns 1998;
Principle 5. Confirm Client Understanding 33(Suppl):S61–7.
15. Whitlock EP, Orleans CT, Pender N, Allan J. Evaluating primary care
It is important to ensure that clients have processed the behavioral counseling interventions: an evidence-based approach. Am
information provided and discussed. One technique for J Prev Med 2002;22:267–84.
confirming understanding is to have the client restate the most 16. French RS, Wellings K, Cowan F. How can we help people to choose a
important messages in her or his own words. This teach-back method of contraception? The case for contraceptive decision aids. J Fam
Plann Reprod Health Care 2009;35:219–20.
method can increase the likelihood of the client and provider 17. O’Connor AM, Bennett CL, Stacey D, et al. Decision aids for people
reaching a shared understanding, and has improved compliance facing health treatment or screening decisions. Cochrane Database Syst
with treatment plans and health outcomes (26,27). Using the Rev 2009;CD001431.
18. Cowley CB, Farley T, Beamis K. “Well, maybe I’ll try the pill for just a
teach-back method early in the decision-making process will few months...”: brief motivational and narrative-based interventions to
help ensure that a client has the opportunity to understand her encourage contraceptive use among adolescents at high risk for early
or his options and is making informed choices (28). childbearing. Fam Syst Health 2002;20:183–204.
19. Gilliam M, Knight S, McCarthy M Jr. Success with oral contraceptives:
References a pilot study. Contraception 2004;69:413–8.
20. Namerow PB, Weatherby N, Williams-Kaye J. The effectiveness of
1. Lambert M. Implications of outcome research for psychotherapy contingency-planning counseling. Fam Plann Perspect 1989;21:115–9.
integration. In: Norcross J, Goldfind M, eds. Handbook of psychotherapy 21. Berger DK, Perez G, Kyman W, et al. Influence of family planning
integration. New York, NY: Basic Books; 1992:94–129. counseling in an adolescent clinic on sexual activity and contraceptive
2. Adams-Skinner J, Exner T, Pili C, Wallace B, Hoffman S, Leu CS. The use. J Adolesc Health Care 1987;8:436–40.
development and validation of a tool to assess nurse performance in dual 22. Winter L, Breckenmaker LC. Tailoring family planning services to the
protection counseling. Patient Educ Couns 2009;76:265–71. special needs of adolescents. Fam Plann Perspect 1991;23:24–30.
3. Brindis CD, Geierstanger SP, Wilcox N, McCarter V, Hubbard A. 23. Chewning B, Mosena P, Wilson D, et al. Evaluation of a computerized
Evaluation of a peer provider reproductive health service model for contraceptive decision aid for adolescent patients. Patient Educ Couns
adolescents. Perspect Sex Reprod Health 2005;37:85–91. 1999;38:227–39.
4. Nobili MP, Piergrossi S, Brusati V, Moja EA. The effect of patient- 24. Garbers S, Meserve A, Kottke M, Hatcher R, Chiasson MA. Tailored health
centered contraceptive counseling in women who undergo a voluntary messaging improves contraceptive continuation and adherence: results from
termination of pregnancy. Patient Educ Couns 2007;65:361–8. a randomized controlled trial. Contraception 2012;86:536–42.
5. Proctor A, Jenkins TR, Loeb T, Elliot M, Ryan A. Patient satisfaction 25. Garbers S, Meserve A, Kottke M, Hatcher R, Ventura A, Chiasson MA.
with 3 methods of postpartum contraceptive counseling: a randomized, Randomized controlled trial of a computer-based module to improve
prospective trial. J Reprod Med 2006;51:377–82. contraceptive method choice. Contraception 2012;86:383–90.
6. Fiore M, Jaén C, Baker T, Bailey W, Benowitz N, Curry S. Treating 26. McMahon SR, Rimsza ME, Bay RC. Parents can dose liquid medication
tobacco use and dependence: 2008 update. Clinical practice guideline. accurately. Pediatrics 1997;100:330–3.
Rockville, MD: US Department of Health and Human Services; 2008. 27. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician
Available at http://www.ncbi.nlm.nih.gov/books/NBK63952. communication with diabetic patients who have low health literacy. Arch
7. Boise R, Petersen R, Curtis KM, et al. Reproductive health counseling Intern Med 2003;163:83–90.
at pregnancy testing: a pilot study. Contraception 2003;68:377–83. 28. National Quality Forum. Health literacy: a linchpin in achieving national
8. Custo G, Saitto C, Cerza S, Sertoli G. The adjusted contraceptive score goals for health and healthcare, Issue Brief #13 2009. Available at http://www.
(ACS) improves the overall performance of behavioural and barrier qualityforum.org/Publications/2009/03/Health_Literacy__A_Linchpin_in_
contraceptive methods. Adv Contracept Deliv Syst 1987;3:367–73. Achieving_National_Goals_for_Health_and_Healthcare.aspx.
46 MMWR / April 25, 2014 / Vol. 63 / No. 4

Appendix D
Contraceptive Effectiveness
Providers should counsel clients about the effectiveness unintended pregnancy during the first year of use, and is
of different contraceptive methods. Method effectiveness estimated for both typical and perfect use (Table).
is measured as the percentage of women experiencing an
TABLE. Percentage of women experiencing an unintended pregnancy during the first year of typical use* and the first year of perfect use† of
contraception and the percentage continuing use at the end of the first year — United States
% of women experiencing an unintended pregnancy
within the first year of use
Method Typical use Perfect use % of women continuing use at 1 year§
No method¶ 85.0 85.0
Spermicides** 28.0 18.0 42.0
Fertility awareness-based methods 24.0 47.0
Standard days method†† 5.0
2-day method†† 4.0
Ovulation method†† 3.0
Symptothermal method 0.4
Withdrawal 22.0 4.0 46.0
Sponge 36.0
Parous women 24.0 20.0
Nulliparous women 12.0 9.0
Condom§§
Female 21.0 5.0 41.0
Male 18.0 2.0 43.0
Diaphragm¶¶ 12.0 6.0 57.0
Combined pill and progestin-only pill 9.0 0.3 67.0
Evra patch 9.0 0.3 67.0
NuvaRing 9.0 0.3 67.0
Depo-Provera 6.0 0.2 56.0
Intrauterine contraceptives
ParaGard (copper T) 0.8 0.6 78.0
Mirena (LNG) 0.2 0.2 80.0
Implanon 0.05 0.05 84.0
Female sterilization 0.5 0.5 100.0
Male sterilization 0.15 0.1 100.0
Emergency Contraceptives: Emergency contraceptive pills or insertion of a copper intrauterine contraceptive after unprotected intercourse substantially reduces the risk of pregnancy.***
Lactational Amenorrhea Method: LAM is a highly effective, temporary method of contraception.†††
Source: Adapted from Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Nelson AL, Cates W, Kowal D, Policar M, eds. Contraceptive technology: 20th revised ed. New York, NY: Ardent
Media; 2011.
* Among typical couples who initiate use of a method (not necessarily for the first time), the percentage of couples who experience an accidental pregnancy during the first year if they
do not stop use for any other reason. Estimates of the probability of pregnancy during the first year of typical use for spermicides and the diaphragm are taken from the 1995 National
Survey of Family Growth corrected for underreporting of abortion; estimates for fertility awareness-based methods, withdrawal, the male condom, the pill, and Depo-Provera are taken
from the 1995 and 2002 National Survey of Family Growth corrected for underreporting of abortion. See the text for the derivation of estimates for the other methods.
† Among couples who initiate use of a method (not necessarily for the first time) and who use it perfectly (both consistently and correctly), the percentage of couples who experience an
accidental pregnancy during the first year if they do not stop use for any other reason. See the text for the derivation of the estimate for each method.
§ Among couples attempting to avoid pregnancy, the percentage of couples who continue to use a method for 1 year.
¶ The percentages becoming pregnant in columns labeled “typical use” and “perfect use” are based on data from populations in which contraception is not used and from women who
cease using contraception to become pregnant. Among such populations, approximately 89% become pregnant within 1 year. This estimate was lowered slightly (to 85%) to represent
the percentage of women who would become pregnant within 1 year among women now relying on reversible methods of contraception if they abandoned contraception altogether.
** Foams, creams, gels, vaginal suppositories, and vaginal film.
†† The Ovulation and 2-day methods are based on evaluation of cervical mucus. The Standard Days method avoids intercourse on cycle days 8 through 19. The Symptothermal method is
a double-check method based on evaluation of cervical mucus to determine the first fertile day and evaluation of cervical mucus and temperature to determine the last fertile day.
§§ Without spermicides.
¶¶ With spermicidal cream or jelly.
*** Ella, Plan B One-Step, and Next Choice are the only dedicated products specifically marketed for emergency contraception. The label for Plan B One-Step (1 dose is 1 white pill) says to
take the pill within 72 hours after unprotected intercourse. Research has indicated that all of the brands listed here are effective when used within 120 hours after unprotected intercourse.
The label for Next Choice (1 dose is 1 peach pill) says to take one pill within 72 hours after unprotected intercourse and another pill 12 hours later. Research has indicated that that both
pills can be taken at the same time with no decrease in efficacy or increase in side effects and that they are effective when used within 120 hours after unprotected intercourse. The Food
and Drug Administration has in addition declared the following 19 brands of oral contraceptives to be safe and effective for emergency contraception: Ogestrel (1 dose is 2 white pills),
Nordette (1 dose is 4 light-orange pills), Cryselle, Levora, Low-Ogestrel, Lo/Ovral, or Quasence (1 dose is 4 white pills), Jolessa, Portia, Seasonale or Trivora (1 dose is 4 pink pills), Seasonique
(1 dose is 4 light-blue-green pills), Enpresse (1 dose is 4 orange pills), Lessina (1 dose is 5 pink pills), Aviane or LoSeasonique (one dose is 5 orange pills), Lutera or Sronyx (1 dose is 5 white
pills), and Lybrel (1 dose is 6 yellow pills).
††† However, for effective protection against pregnancy to be maintained, another method of contraception must be used as soon as menstruation resumes, the frequency or duration of
breastfeeds is reduced, bottle feeds are introduced, or the baby reaches age 6 months.
MMWR / April 25, 2014 / Vol. 63 / No. 4 47

Appendix E
Strategies for Providing Information to Clients
The client should receive and understand the information • Toolkit for Making Written Material Clear and Effective,
she or he needs to make informed decisions and follow Part 11; Understanding and using the “Toolkit Guidelines
treatment plans. This requires careful attention to how for Culturally Appropriate Translation,” provided by the
information is communicated. The following strategies can Centers for Medicare and Medicaid Services (available at
make information more readily comprehensible to clients: http://www.cms.gov/outreach-and-education/outreach/
writtenmaterialstoolkit/downloads/toolkitpart11.pdf ).
Strategies for Providing Information to Clients The amount of information presented should be limited and
Educational materials should be provided that are clear and emphasize essential points. Providers should focus on needs
easy to understand. Educational materials delivered through and knowledge gaps identified during the assessment. Many
any one of a variety of media (for example, written, audio/ clients immediately forget or remember incorrectly much of
visual, computer/web-based) need to be presented in a format the information provided. This problem is exacerbated as
that is clear and easy to interpret by clients with a 4th to 6th more information is presented (7–9). Limiting the amount
grade reading level (1–3). Many adults have only a basic of information presented and highlighting important facts
ability to obtain, process, and understand health information by presenting them first improves comprehension (10–14).
necessary to make decisions about their health (4). Making Numeric quantities should be communicated in a way that
easy-to-access materials enhances informed decision-making is easily understood. Whenever possible, providers should use
(1–3). Test all educational materials with the intended natural frequencies and common denominators (for example,
audiences for clarity and comprehension before wide-scale use. 85 of 100 sexually active women are likely to get pregnant
The following evidence-based tools provide recommendations within 1 year using no contraceptive, as compared with 1
for increasing the accessibility of materials through careful in 100 using an IUD or implant), and display quantities in
consideration of content, organization, formatting, and graphs and visuals. Providers also should avoid using verbal
writing style: descriptors without numeric quantities (for example, sexually
• Health Literacy Universal Precautions Toolkit, provided active women using an IUD or implant almost never become
by the Agency for Healthcare Research and Quality pregnant). Finally, they should quantify risk in absolute rather
(available at http://www.ahrq.gov/qual/literacy), than relative terms (for example, “the chance of unintended
• Toolkit for Making Written Material Clear and Effective, pregnancy is reduced from 8 in 100 to 1 in 100 by switching
provided by the Centers for Medicare and Medicaid Services from oral contraceptives to an IUD” versus the chance of
(available at http://www.cms.gov/WrittenMaterialsToolkit), unintended pregnancy is reduced by 87%). Numeracy is more
and highly correlated with health outcomes than the ability to read
• Health Literacy Online, provided by the Office of Disease or listen effectively (15). The strategies listed above can help
Prevention and Health Promotion (available at http:// clients interpret numeric quantities correctly (16–28).
www.health.gov/healthliteracyonline). Balanced information on risks and benefits should be
Information should be delivered in a manner that is presented and messages framed positively. In addition to
culturally and linguistically appropriate. In presenting discussing risks, contraindications, and warnings, providers
information it is important to be sensitive to the client’s should discuss the advantages and benefits of contraception.
cultural and linguistic preferences (5,6). Ideally information In presenting this information, providers should express risks
should be presented in the client’s primary language, but and benefits in a common format (for example, do not present
translations and interpretation services should be available risks in relative terms and benefits in absolute terms), and frame
when necessary. Information presented must also be culturally messages in positive terms (for example “99 out of 100 women
appropriate, reflecting the client’s beliefs, ethnic background, find this a safe method with no side effects,” versus “1 out of
and cultural practices. Tools for addressing cultural and 100 women experience noticeable side effects”). Many clients
linguistic differences and preferences include prefer to receive a balance of information on risks and benefits
• Health Literacy Universal Precautions Toolkit, provided (29), and using a common format avoids bias in presentation
by the Agency for Healthcare Research and Quality of information (18,22,26,30). Framing messages positively
(available at http://www.ahrq.gov/qual/literacy), and increases acceptance and comprehension (18,22,31,32).
48 MMWR / April 25, 2014 / Vol. 63 / No. 4

Active client engagement should be encouraged. Providers 15. Berkman N, Sheridan S, Donahue K, et al. Health literacy interventions
should use educational materials that encourage active and outcomes: an updated systematic review. Evidence Report/
Technology Assesment No. 199. Rockville, MD: Agency for Healthcare
information processing (e.g., questions, quizzes, fill-in-the- Research and Quality; 2011.
blank, web-based games, and activities). In addition, they 16. Berry DC. Informing people about the risks and benefits of medicines:
should be sure the client has an opportunity to discuss the implications for the safe and effective use of medicinal products. Curr
Drug Saf 2006;1:121–6.
information provided, and when speaking with a client, 17. Berry DC, Raynor DK, Knapp P, Bersellini E. Patients’ understanding
providers should engage her or him actively. Research has of risk associated with medication use: impact of European Commission
indicated that interactive materials improve knowledge guidelines and other risk scales. Drug Saf 2003;26:1–11.
18. Edwards A, Elwyn G, Mulley A. Explaining risks: turning numerical
of contraceptive risks, benefits, and correct method use data into meaningful pictures. BMJ 2002;324:827–30.
(33–35). Clients also value spoken information (29,36); and 19. Galesic M, Gigerenzer G, Straubinger N. Natural frequencies help older
educational materials, when delivered by a provider, more adults and people with low numeracy to evaluate medical screening tests.
effectively increase knowledge (10,37). In particular, presenting Med Decis Making 2009;29:368–71.
20. Garcia-Retamero R, Galesic M. Communicating treatment risk reduction
information in a question and answer format is more effective to people with low numeracy skills: a cross-cultural comparison. Am J
than simply presenting the information (10,15,37–41). Public Health 2009;99:2196–202.
21. Garcia-Retamero R, Galesic M, Gigerenzer G. Do icon arrays help reduce
References denominator neglect? Med Decis Making 2010;30:672–84.
22. Gigerenzer G, Edwards A. Simple tools for understanding risks: from
1. Centers for Medicare and Medicaid Services. Toolkit for making written innumeracy to insight. BMJ 2003;327:741–4.
material clear and effective. Baltimore, MD: Centers for Medicare and 23. Knapp P, Gardner PH, Raynor DK, Woolf E, McMillan B. Perceived
Medicaid Services; 2011. risk of tamoxifen side effects: a study of the use of absolute frequencies
2. US Department of Health and Human Services, Office of Disease or frequency bands, with or without verbal descriptors. Patient Educ
Prevention and Health Promotion. Health literacy online: A guide to Couns 2010;79:267–71.
writing and designing easy-to-use health Web sites. Washington, DC: 24. Kurz-Milcke E, Gigerenzer G, Martignon L. Transparency in risk
US Department of Health and Human Services; 2010. communication: graphical and analog tools. Ann N Y Acad Sci
3. DeWalt D, Callahan L, Hawk V, et al. Health literacy universal 2008;1128:18–28.
precautions toolkit. AHRQ Publication No. 10–0046-EF. Rockville, 25. Lipkus IM. Numeric, verbal, and visual formats of conveying health
MD: Agency for Healthcare Research and Quality; 2010. risks: suggested best practices and future recommendations. Med Decis
4. Kutner M, Greenberg E, Jin Y, Paulsen C. The health literacy of America’s Making 2007;27:696–713.
adults: results from the 2003 National Assessment of Adult Literacy 26. Paling J. Strategies to help patients understand risks. BMJ 2003;
(NCES 2006–483). Washington, DC: U.S. Department of Education: 327:745–8.
National Center for Education Statistics; 2006. 27. Skolbekken JA. Communicating the risk reduction achieved by
5. Olavarria M, Beaulac J, Belanger A, Young M, Aubry T. Organizational cholesterol reducing drugs. BMJ 1998;316:1956–8.
cultural competence in community health and social service organizations: 28. Visschers VH, Meertens RM, Passchier WW, de Vries NN. Probability
how to conduct a self-assessment. J Cult Divers 2009;16:140–50. information in risk communication: a review of the research literature.
6. Tucker C. Reducing health disparities by promoting patient-centered Risk Anal 2009;29:267–87.
culturally and linguistically sensitive/competent health care. U.S. 29. Raynor DK, Blenkinsopp A, Knapp P, et al. A systematic review of
Department of Health and Human Services Advisory Committee on quantitative and qualitative research on the role and effectiveness of
Minority Health, US Public Health Service; 2009. written information available to patients about individual medicines.
7. Anderson JL, Dodman S, Kopelman M, Fleming A. Patient information Health Technol Assess 2007;11:iii, 1–160.
recall in a rheumatology clinic. Rheumatol Rehabil 1979;18:18–22. 30. Fahey T, Griffiths S, Peters TJ. Evidence based purchasing: understanding
8. Crane JA. Patient comprehension of doctor-patient communication on results of clinical trials and systematic reviews. BMJ 1995;311:1056–9,
discharge from the emergency department. J Emerg Med 1997;15:1–7. discussion 9–60.
9. McGuire LC. Remembering what the doctor said: organization and adults’ 31. Armstrong K, Schwartz JS, Fitzgerald G, Putt M, Ubel PA. Effect of framing
memory for medical information. Exp Aging Res 1996;22:403–28. as gain versus loss on understanding and hypothetical treatment choices:
10. Little P, Griffin S, Kelly J, Dickson N, Sadler C. Effect of educational survival and mortality curves. Med Decis Making 2002;22:76–83.
leaflets and questions on knowledge of contraception in women taking 32. Gurm HS, Litaker DG. Framing procedural risks to patients: is 99%
the combined contraceptive pill: randomised controlled trial. BMJ safe the same as a risk of 1 in 100? Acad Med 2000;75:840–2.
1998;316:1948–52. 33. Paperny DM, Starn JR. Adolescent pregnancy prevention by health
11. McGee J. Toolkit for making written material clear and effective: education computer games: computer-assisted instruction of knowledge
Baltimore, MD: Centers for Medicare and Medicaid Services; 2010. and attitudes. Pediatrics 1989;83:742–52.
Available at http://www.cms.gov/WrittenMaterialsToolkit. 34. Reis J, Tymchyshyn P. A longitudinal evaluation of computer-assisted
12. Peters E, Dieckmann N, Dixon A, Hibbard JH, Mertz CK. Less is more instruction on contraception for college students. Adolescence
in presenting quality information to consumers. Med Care Res Rev 1992;27:803–11.
2007;64:169–90. 35. Roberto AJ, Zimmerman RS, Carlyle KE, Abner EL, Cupp PK, Hansen
13. Steiner MJ, Dalebout S, Condon S, Dominik R, Trussell J. Understanding GL. The effects of a computer-based pregnancy, STD, and HIV
risk: a randomized controlled trial of communicating contraceptive prevention intervention: a nine-school trial. Health Commun
effectiveness. Obstet Gynecol 2003;102:709–17. 2007;21:115–24.
14. Berry DC, Michas IC. Rosis F. Evaluating explanations about drug 36. Grime J, Blenkinsopp A, Raynor DK, Pollock K, Knapp P. The role and
prescriptions: Effects of varying the nature of information about side value of written information for patients about individual medicines: a
effects and its relative position in explanations. Psychol Health systematic review. Health Expect 2007;10:286–98.
1998;13:767–84.
MMWR / April 25, 2014 / Vol. 63 / No. 4 49

37. DeLamater J, Wagstaff DA, Havens KK. The impact of a culturally 40. Eldridge GD, St Lawrence JS, Little CE, et al. Evaluation of the HIV
appropriate STD/AIDS education intervention on black male risk reduction intervention for women entering inpatient substance
adolescents’ sexual and condom use behavior. Health Educ Behav abuse treatment. AIDS Educ Prev 1997;9(Suppl):62–76.
2000;27:454–70. 41. Jaccard J. Unlocking the contraceptive conundrum. Washington, DC:
38. McMahon SR, Rimsza ME, Bay RC. Parents can dose liquid medication The National Campaign to Prevent Teen and Unplanned Pregnancy;
accurately. Pediatrics 1997;100:330–3. 2009. Available at http://thenationalcampaign.org/resource/
39. Belcher L, Kalichman S, Topping M, et al. A randomized trial of a brief unlocking-contraception-conundrum.
HIV risk reduction counseling intervention for women. J Consult Clin
Psychol 1998;66:856–61.
50 MMWR / April 25, 2014 / Vol. 63 / No. 4

Appendix F
Screening Services For Which Evidence Does Not Support Screening
The following services have been given a D recommendation • Ovarian cancer: USPSTF recommends against routine
from the U.S. Preventive Services Task Force (USPSTF), which screening for ovarian cancer (9).
indicates that the potential harms of routine screening outweigh The USPSTF has recommended against offering the
the benefits. Providers should not perform these screening services. following services to men:
The USPSTF has recommended against offering the • Prostate cancer: USPSTF recommends against prostate-
following services to women and men: specific antigen (PSA)-based screening for prostate cancer (10).
• Asymptomatic bacteriuria: USPSTF recommends • Testicular cancer: USPSTF recommends against screening
against screening for asymptomatic bacteriuria in men for testicular cancer in adolescent or adult males (11).
and nonpregnant women (1).
References
• Gonorrhea: USPSTF recommends against routine
screening for gonorrhea infection in men and women who 1. US Preventive Services Task Force. Screening for asymptomatic bacteriuria
in adults. Rockville, MD: US Department of Health and Human Services,
are at low risk of infection (2). Agency for Healthcare Research and Quality; 2008. Available at http://
• Hepatitis B: USPSTF recommends against routinely www.uspreventiveservicestaskforce.org/uspstf/uspsbact.htm.
screening the general asymptomatic population for 2. US Preventive Services Task Force. Screening for gonorrhea. Rockville,
MD: US Department of Health and Human Services, Agency for
chronic hepatitis B virus infection (3). Healthcare Research and Quality; 2005. Available at http://www.
• Herpes simplex virus (HSV): USPSTF recommends uspreventiveservicestaskforce.org/uspstf/uspsgono.htm.
against routine serological screening for HSV in 3. US Preventive Services Task Force. Screening for hepatitis B infection.
asymptomatic adolescents and adults (4). for Healthcare Research and Quality; 2004. Available at http://www.
• Syphilis: USPSTF recommends against screening of uspreventiveservicestaskforce.org/uspstf/uspshepb.htm.
asymptomatic persons who are not at increased risk of 4. US Preventive Services Task Force. Screening for genital herpes:
syphilis infection (5). recommendation statement. Rockville, MD: US Department of Health
and Human Services, Agency for Healthcare Research and Quality;
The USPSTF has recommended against offering the 2005. Available at http://www.uspreventiveservicestaskforce.org/
following services to women: uspstf05/herpes/herpesrs.htm.
• BRCA mutation testing for breast and ovarian cancer 5. US Preventive Services Task Force. Screening for syphilis infection.
susceptibility: USPSTF recommends against routine for Healthcare Research and Quality; 2004. Available at http://www.
referral for genetic counseling or routine breast cancer uspreventiveservicestaskforce.org/uspstf/uspssyph.htm.
susceptibility gene (BRCA) testing for women whose family 6. US Preventive Services Task Force. Risk assessment, genetic counseling, and
genetic testing for BRCA-related cancer in women. Rockville, MD: US
history is not associated with an increased risk of deleterious Department of Health and Human Services, Agency for Healthcare Research
mutations in breast cancer susceptibility gene 1 (BRCA1) or and Quality; 2013. Available at http://www.uspreventiveservicestaskforce.
breast cancer susceptibility gene 2 (BRCA2) (6). However, org/uspstf/uspsbrgen.htm.
USPSTF continues to recommend that women whose family 7. US Preventive Services Task Force. Screening for breast cancer. Rockville,
MD: US Department of Health and Human Services, Agency for
history is associated with an increased risk of deleterious Healthcare Research and Quality; 2009. Available at http://www.
mutations in BRCA1 or BRCA2 genes be referred for genetic uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm.
counseling and evaluation for BRCA testing. 8. US Preventive Services Task Force. Screening for cervical cancer.
• Breast self-examination: USPSTF recommends against for Healthcare Research and Quality; 2012. Available at www.
teaching breast self-examination (7). uspreventiveservicestaskforce.org/uspstf11/cervcancer/cervcancerrs.htm.
• Cervical cytology: USPSTF recommends against routine 9. US Preventive Services Task Force. Screening for ovarian cancer: U.S.
Preventive Services Task Force reaffirmation recommendation statement.
screening for cervical cancer with cytology (Pap smear) in Rockville, MD: US Department of Health and Human Services, Agency
the following groups: women aged <21 years, women aged for Healthcare Research and Quality; 2012. Available at http://www.
>65 years who have had adequate prior screening and are uspreventiveservicestaskforce.org/uspstf12/ovarian/ovarcancerrs.htm.
not otherwise at high risk for cervical cancer, women who 10. US Preventive Services Task Force. Screening for prostate cancer.
have had a hysterectomy with removal of the cervix and for Healthcare Research and Quality; 2012. Available at http://www.
who do not have a history of a high-grade precancerous uspreventiveservicestaskforce.org/prostatecancerscreening.htm.
lesion (i.e., cervical intraepithelial neoplasia grade 2 or 3) 11. US Preventive Services Task Force. Screening for testicular cancer.
or cervical cancer. USPSTF recommends against screening for Healthcare Research and Quality; 2011. Available at http://www.
for cervical cancer with HPV testing, alone or in uspreventiveservicestaskforce.org/uspstf/uspstest.htm.
combination with cytology, in women aged <30 years (8).
MMWR / April 25, 2014 / Vol. 63 / No. 4 51

Lead Authors
Loretta Gavin, PhD, Division of Reproductive Health, CDC
Susan Moskosky, MS, Office of Population Affairs, CDC
Systematic Review Authors and Presenters
Anna Brittain, MHS, Division of Reproductive Health, CDC
Marion Carter, PhD, Division of Reproductive Health, CDC
Kathryn Curtis, PhD, Division of Reproductive Health, CDC
Emily Godfrey, MD, Division of Reproductive Health, CDC
Arik V. Marcell, MD, The Johns Hopkins University and the Male Training Center
Cassondra Marshall, MPH, Division of Reproductive Health, CDC
Karen Pazol, PhD, Division of Reproductive Health, CDC
Naomi Tepper, MD, Division of Reproductive Health, CDC
Marie Tiller, PhD, MANILA Consulting Group, Inc.
Stephen Tregear, DPhil, MANILA Consulting Group, Inc.
Michelle Tregear, PhD, MANILA Consulting Group, Inc.
Jessica Williams, MPH, MANILA Consulting Group, Inc.
Lauren Zapata, PhD, Division of Reproductive Health, CDC
Expert Work Group
Courtney Benedict, MSN, Marin Community Clinics
Jan Chapin, MPH, American College of Obstetricians and Gynecologists
Clare Coleman, President and CEO, National Family Planning and Reproductive Health Association
Vanessa Cullins, MD, Planned Parenthood Federation of America
Daryn Eikner, MS, Family Planning Council
Jule Hallerdin, MN, Advisor to the Office of Population Affairs
Mark Hathaway, MD, Unity Health Care and Washington Hospital Center
Seiji Hayashi, MD, Bureau of Primary Health Care, Health Resources and Services Administration
Beth Jordan, MD, Association of Reproductive Health Professionals
Ann Loeffler, MSPH, John Snow Research and Training Institute
Tom Miller, MD, Alabama Department of Health
Deborah Nucatola, MD, Planned Parenthood Federation of America
Michael Policar, MD, State of California and UCSF Bixby Center
Adrienne Stith-Butler, PhD, Keck Center of the National Academies
Denise Wheeler, ARNP, Iowa Department of Public Health
Gayla Winston, MPH, Indiana Family Health Council
Jacki Witt, MSN, Clinical Training Center for Family Planning, University of Missouri—Kansas City
Jamal Gwathney, MD, Bureau of Primary Health Care, Health Resources and Services Administration
Technical Panel on Women’s Clinical Services
Courtney Benedict, MSN, Marin Community Clinics
Janet Chapin, MPH, American College of Obstetricians and Gynecologists
Elizabeth DeSantis, MSN, South Carolina Department of Health and Environmental Control
Linda Dominguez, CNP, Southwest Women’s Health
Eileen Dunne, MD, Division of STD Prevention, CDC
Jamal K. Gwathney, MD, Bureau of Primary Health Care, Health Resources and Services Administration
Jule Hallerdin, Consultant Advisor
Mark Hathaway, MD, Washington Hospital Center
Arik V. Marcell, MD, Johns Hopkins University and the Male Training Center
Cheri Moran, University of Illinois Medical Center at Chicago
Deborah Nucatola, MD, Planned Parenthood Federation of America
Michael Policar, MD, Family PACT Program - California State Office of Family Planning
Pablo Rodriguez, MD, Women’s Care Inc., Providence Office
Denise Wheeler, ARNP, Iowa Department of Public Health
52 MMWR / April 25, 2014 / Vol. 63 / No. 4

Technical on Men’s Clinical Services

Linda Creegan, FNP, California STD/HIV Prevention Training Center
Dennis Fortenberry, MD, Indiana University School of Medicine
Emily Godfrey, MD, University of Illinois at Chicago
Wendy Grube, PhD, University of Pennsylvania School of Nursing
Elissa Meites, MD, Division of STD Prevention, CDC
Anne Rompalo, MD, Johns Hopkins University
Thomas Walsh, MD, University of Washington Medical Center
Sandra Wolf, MD, Women’s Care Center, Philadelphia
Technical Panel on Adolescents
Claire Brindis, DrPH, University of California, San Francisco
Gale Burstein, MD, SUNY at Buffalo School of Medicine and Biomedical Sciences, Department of Pediatrics
Laura Davis, MA, Advocates for Youth
Patricia J. Dittus, PhD, Division of STD Prevention, CDC
Paula Duncan, MD, University of Vermont College of Medicine
Carol Ford, MD, The Children’s Hospital of Philadelphia
Melissa Gilliam, MD, The University of Chicago
Mark Hathaway, MD, Unity Health Care & Washington Hospital Center
Deborah Kaplan, PhD, New York City Department of Health and Mental Hygiene
Brent C. Miller, PhD, Utah State University
Elizabeth M. Ozer, PhD, Division of Adolescent Medicine, University of California, San Francisco
John Santelli, MD, Columbia University, Mailman School of Public Health
Technical Panel on Counseling and Education
Beth Barnet, MD, University of Maryland
Betty Chewning, PhD, University of Wisconsin School of Pharmacy
Christine Dehlendorf, MD, University of California, San Francisco
Linda Dominguez, CNP, Southwest Women’s Health
Jillian Henderson, PhD, University of California, San Francisco
James Jaccard, PhD, New York University
Beth Jordan, MD, Association of Reproductive Health Professionals—East
David Kaplan, PhD, American Counseling Association
Alicia Luchowski, American Congress of Obstetricians and Gynecologists
Merry-K Moos, FNP, University of North Carolina at Chapel Hill
Patricia Murphy, DrPH, University of Utah College of Nursing
Elizabeth O’Connor, PhD, Kaiser Permanente Center for Health Research
Jeff Peipert, MD, Washington University in St. Louis
Technical Panel on Quality Improvement
Davida Becker, PhD, Bixby Center for Global Reproductive Health University of California, San Francisco
Peter Briss, MD, National Center for Chronic Disease Prevention and Health Promotion, CDC
Denise Dougherty, PhD, Agency for Healthcare Research and Quality
Daryn Eikner, MS, Family Planning Council
Christina I. Fowler, PhD, RTI International
Evelyn Glass, MSPH, Consultant Advisor
Yvonne Hamby, MPH, Regional Quality Improvement and Infertility Prevention Programs
A. Seiji Hayashi, MD, Bureau of Primary Health Care, Health Resources and Services Administration
Michael D. Kogan, PhD, Health Resources and Services Administration /Maternal and Child Health Bureau
Tom Miller, MD, Alabama Department of Health
Sam Posner, PhD, National Center for Chronic Disease Prevention and Health Promotion, CDC
Donna Strobino, PhD, Johns Hopkins University
Amy Tsui, PhD, Johns Hopkins Bloomberg School of Public Health
Reva Winkler, MD, National Quality Forum
MMWR / April 25, 2014 / Vol. 63 / No. 4 53

Adivsors on Community Outreach and Participation*

Paula Baraitser, MBBS, Kings College Hospital NHS Foundation Trust/Health Protection Agency
Joy Baynes, MPH, Advocates for Youth
Diane Chamberlain, California Family Health Council
Clare Coleman, National Family Planning & Reproductive Health Association
Emily Godfrey, MD, University of North Carolina and Division of Reproductive Health, CDC
Rachel Gold, MPA, Guttmacher Institute
Rachel Kachur, MPH, Division of STD Prevention, CDC
Michelle Kegler, PhD, Rollins School of Public Health, Emory
Eleanor McLellan-Lemal, PhD, Division of HIV/AIDS Prevention, CDC
Paula Parker-Sawyers, National Campaign to Prevent Teen and Unplanned Pregnancy
Denise Wheeler, MS, Iowa Department of Public Health
Gayla Winston, MPH, Indiana Family Health Council, Inc.
CDC and Office of Population Affairs Reviewers
Wanda Barfield, MD, Division of Reproductive Health, CDC
Gail Bolan, MD, Division of STD Prevention, CDC
Linda Dahlberg, PhD, Division of Violence Prevention, CDC
Patricia Dietz, PhD, Division of Reproductive Health, CDC
Sherry Farr, PhD, Division of Reproductive Health, CDC
Evelyn Glass, MSPH, Office of Population Affairs
Tamara Haegerich, PhD, Division of Violence Prevention, CDC
David Johnson, MPH, Office of Population Affairs
Pamela Kania, MS, Office of Population Affairs
Marilyn Keefe, MPH, Deputy Assistant Secretary for Population Affairs
Dmitry Kissin, MD, Division of Reproductive Health, CDC
Nancy Mautone-Smith, MSW, Office of Population Affairs
Jacqueline Miller, MD, Division of Cancer Prevention and Control, CDC
Sam Posner, PhD, National Center for Chronic Disease and Health Promotion, CDC
Cheryl Robbins, PhD, Division of Reproductive Health, CDC
Lance Rodewald, MD, Division of Immunization Services, CDC
Mona Saraiya, MD, Division of Cancer Prevention and Control, CDC
Van Tong, MPH, Division of Reproductive Health, CDC
Lee Warner, PhD, Division of Reproductive Health, CDC
Kim Workowski, MD, Division of STD Prevention, CDC
External Reviewers
Paula Braverman, MD, Department of Pediatrics at the University of Cincinnati
Claire Brindis, DrPH, University of California–San Francisco
Sarah Brown, MPH, National Campaign to Prevent Teen and Unplanned Pregnancy
Marji Gold, MD, Albert Einstein School of Medicine
Milton Kotelchuck, PhD, Massachusetts General Hospital for Children and Harvard Medical School
David Levine, MD, Morehouse School of Medicine
Pamela Murray, MD, West Virginia University School of Medicine
Competing interests for the development of these guidelines were not assessed.
* These persons made important contributions to a discussion about community outreach and participation. A decision was made to narrow the focus of this report
to clinical services, so recommendations informed by the input of these persons will be published separately.
54 MMWR / April 25, 2014 / Vol. 63 / No. 4

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Morbidity and Mortality Weekly Report

Providing Quality Family Planning Services

Continuing Education Examination available at http://www.cdc.gov/mmwr/cme/conted.html.

U.S. Department of Health and Human Services

MMWR Editorial Board

Providing Quality Family Planning Services

MMWR / April 25, 2014 / Vol. 63 / No. 4 1

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report, health services are divided into three main categories:

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Determine the need for services among

Reason for visit is related to Initial reason for visit is not

Assess need for services related

Clients also should be Sexually If services are not needed at this

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BOX 2. Recommended questions to ask when assessing a client’s

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TABLE 4. Suggested measures of the quality of family planning services

permanent. Examples of steps that may be taken to improve Conclusion

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References 5. Frey KA, Navarro S, Kotelchuck M, Lu M. The clinical content of

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TABLE 1. Select Panel on Preconception Care grading system

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TABLE 4. Levels of certainty regarding net benefit

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Contraceptive Services — Broad

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Contraceptive Services — absence of harmful effects from comprehensive sexual health

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positive association between confidentiality and intention to Adolescent Services —