摘要：Objectives. To describe a community-wide contraception initiative and assess changes in method use when cost and access barriers are removed in an environment with client-centered counseling. Methods. HER Salt Lake is a prospective cohort study occurring during three 6-month periods (September 2015 through March 2017) and nested in a quasiexperimental observational study. The sample was women aged 16 to 45 years receiving new contraceptive services at health centers in Salt Lake County, Utah. Following the control period, intervention 1 removed cost and ensured staffing and pharmacy stocking; intervention 2 introduced targeted electronic outreach. We used logistic regression and interrupted time series regression analyses to assess impact. Results. New contraceptive services were provided to 4107 clients in the control period, 3995 in intervention 1, and 3407 in intervention 2. The odds of getting an intrauterine device or implant increased 1.6 times (95% confidence interval [CI] = 1.5, 1.6) during intervention 1 and 2.5 times (95% CI = 2.2, 2.8) during intervention 2, relative to the control period. Time series analysis demonstrated that participating health centers placed an additional 59 intrauterine devices and implants on average per month (95% CI = 13, 105) after intervention 1. Conclusions. Removing client cost and increasing clinic capacity was associated with shifts in contraceptive method mix in an environment with client-centered counseling; targeted electronic outreach further augmented these results. The US unintended pregnancy rate recently declined for the first time in decades, 1 but at 45%, it remains a persistent and costly public health issue associated with an array of adverse social and health outcomes for women, children, and communities. 2–9 Healthy People 2020 aims to improve pregnancy planning and spacing and prevent unintended pregnancy. 10 The availability and affordability of family planning services, including the full range of contraceptive methods, is critical to meeting this goal. Groundbreaking efforts in St. Louis, Missouri 11 ; Iowa 12 ; and Colorado 13 established that eliminating financial barriers contributes to the increased use of highly effective reversible methods, including intrauterine devices (IUDs) and implants. Although increased access to all contraception is critical for women’s autonomy, the increased use of IUDs and implants further reduces population-level unintended pregnancy and abortion rates. 12,14 These efforts laid the foundation for important next steps in implementation research. Utah has unique barriers, including limited public funding for contraceptives, vast rural and frontier areas with limited women’s health care providers, and persistent issues with staffing trained providers and stocking IUDs and implants. In 2014, Utah voted against Medicaid expansion under the Affordable Care Act and, as of 2017, has yet to authorize a Medicaid family planning waiver. A post-Affordable Care Act evaluation determined that 207 350 Utah women were in need of publicly supported family planning services. 15 However, even with the unique barriers and coverage gap, Utah has 1 of the nation’s highest rates of IUD and implant use. 16 This is owing in large part to safety net systems such as Title X, a federal family planning grant program. The Planned Parenthood Association of Utah (PPAU) is the state’s only Title X grantee and is the leading provider of contraceptive services. Eight of the 9 PPAU health centers in Utah participate in Title X; the ninth site does not receive Title X and also provides abortion services. Through Title X, PPAU health centers offer financial support for a broad range of family planning methods and services per Title X grant agreements. The University of Utah Family Planning Program partnered with PPAU to garner community, foundation, and pharmaceutical support for the HER Salt Lake Contraceptive Initiative (HER Salt Lake). Initially, we used the acronym HER to stand for highly effective reversible methods; however, as the initiative progressed we referred to it just as HER Salt Lake—with “her” as emphatic support for the women served, rather than favoring specific methods. Using a reproductive justice framework and incorporating social ecological theory, we considered public policy–, organizational-, community-, interpersonal-, and individual-level factors throughout the initiative. 17,18 HER Salt Lake is a prospective cohort study that occurred during three 6-month periods and that was nested in a quasiexperimental observational study. We have reported on differences in method use between the control period, intervention 1, and intervention 2 in an all-served cohort and a survey arm. Additionally, we evaluated the initiative in the context of IUD and implant use trends before study initiation and compared this with nonparticipating PPAU health centers.
