SEDGWICK MOFFAT
LOGAN
LARIMER
JACKSON
PHILLIPS
WELD
ROUTT
MORGAN
BOULDER
GRAND
YUMA
RIO BLANCO
BROOMFIELD
GILPIN
GARFIELD
SUMMIT
CLEAR CREEK
ADAMS JEFFERSON
EAGLE
ARAPAHOE
ELBERT
DOUGLAS PITKIN
WASHINGTON
DENVER
KIT CARSON
PARK
LAKE
LINCOLN
MESA TELLER
DELTA
EL PASO CHEYENNE
CHAFFEE GUNNISON
KIOWA
FREMONT MONTROSE
CROWLEY OURAY
PUEBLO SAGUACHE
SAN MIGUEL
CUSTER
HINSDALE DOLORES
SAN JUAN
BENT MINERAL HUERFANO RIO GRANDE
MONTEZUMA
ALAMOSA
LA PLATA COSTILLA ARCHULETA
Updated May, 2013
PROWERS
OTERO
CONEJOS
LAS ANIMAS
BACA
Access and Affordability: The Colorado Family Planning Initiative
Changing the Choices
May 2013
Family Planning Unit and Epidemiology, Planning and Evaluation Branch Prevention Services Division The Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South, PSD-WH-A4 / Denver, CO 80246-1530 http://www.cdphe.state.co.us/pp/womens/famplan.htm
Introduction The Colorado Initiative to Reduce Unintended Pregnancy is a comprehensive effort to reduce unintended pregnancy in Colorado. The Colorado Family Planning Initiative (CFPI), managed by the Colorado Department of Public Health and Environment, is a major component of the effort. One of the main objectives of CFPI has been to increase access to family planning services through Colorado’s Title X Family Planning Program, particularly among low-income and uninsured women. In addition, CFPI was designed to improve access to long-acting reversible contraceptive LARC) methods as well as permanent methods (tubal ligations, Essure and vasectomies) so that individuals can access the birth control methods of their choice without the barrier of high initial cost. Beginning in 2009, CFPI funding was distributed to a total of 28 Title X agencies serving 37 of Colorado’s 64 counties.1 Since then, CFPI has provided about $4 million annually to these agencies, in addition to existing federal, state and county funding. The counties served by Title X are home to 95 percent of the state’s low-income population. Nine out of ten Title X clients fall at or below 150 percent of the federal poverty level ($16,755 annual income in 2012 for a single person) and 7 out of 10 are age 29 or younger.
Changes in Number of Clients and LARC Use In fiscal year 2008 (July 2007-June 2008) the Title X program served 48,192 total clients (Figure 1). With the new funding provided by CFPI the number of clients grew to more than 65,000 in FY 10 and FY 11, and leveled off at 63,721 in FY 12, about a one-third increase in patient load. During the same time, the annual number of long-acting reversible contraceptive (IUD and implant) patients more than quadrupled, from 2,275 in FY 08 to 10,140 in FY 12, increasing from 1 in 16 (6.3 percent) female contraceptors in the program in FY 08 to more than 1 in 5 (21.4 percent) in FY 12 (Figure 2). Agency statistics on clients served and percentage LARC methods among female contraceptors are detailed in Table 1 on page 4. In the counties with CFPI funding a total of 20,400 LARC insertions were completed among women of all ages between FY 08 and FY 12. In the combined age group 15 to 29, an estimated 16,900 1
The agencies are listed in Table 1. The counties where the agencies are located are Adams, Arapahoe, Archuleta, Boulder, Broomfield, Cheyenne, Denver, Delta, Douglas, Eagle, El Paso, Gunnison, Huerfano, Jefferson, Kit Carson, Lake, La Plata, Larimer, Las Animas, Lincoln, Logan, Mesa, Moffat, Montrose, Morgan, Phillips, Pitkin, Pueblo, Rio Blanco, Routt, San Miguel, Sedgwick, Summit, Teller, Washington, Weld, and Yuma.
1
FIGURE 1: Total Clients Served
65,581
FIGURE 2: Percent* LARC Clients 25.0%
65,817
21.4%
63,721 20.0%
Number
Percent
48,192
17.7%
53,125 14.3%
15.0% 9.7% 10.0% 6.3% 5.0% 0.0%
FY 08
FY 09
FY 10
FY 11
FY 08
FY 12
FY 09
FY 10
FY 11
FY 12
*The percent is based on the number of female contraceptors seeking services in the 12-month period who received or were using a LARC method.
low-income women received a LARC method over the period. This resulted in more than 1 out of every 10 low-income women ages 15-29 in the counties served receiving a long-acting reversible contraceptive through the Colorado Family Planning Initiative.
Changes in Births In 2007, two years before CFPI began, the low-income fertility rate (births per 1,000 low-income women) was 91 for women ages 15-19, 131 for ages 20-24, and 141 for ages 25-29 in the counties targeted for CFPI funding.2 Between 2007 and 2009, the rates varied only slightly, and expected 2010 rates were 94, 129, and 134, respectively. Any possible decrease in the number of births related to the increase in LARC use was not expected to occur until 2010. CFPI funding was first fully distributed in 2009 and clients receiving
2
Fertility rates for each specific 5-year age group were constructed using births covered by Medicaid as numerators, and estimates of the number of women below 150% of the federal poverty line (which are estimates of women eligible for Medicaid due to pregnancy) as denominators. The Health Statistics Section provided the birth data and the Epidemiology, Planning and Evaluation Branch calculated the number of women below poverty using population and poverty estimates provided by the State Demography Office.
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TABLE 1: Colorado Family Planning Initiative Agency Clients and LARC Users, FY 08 and FY 12 Total Number
LARC Users as Percent
of Clients
of All Contraceptors
Agency Boulder Valley Women’s Health Center Broomfield Health and Human Services
FY 08
FY 12
FY 08
FY 12
2,780
4,275
11
22
332
256
6
18
Children’s Hospital Adolescent Clinic
1,807
5,708
3
51
Colorado Coalition for the Homeless
356
644
4
21
Community Health Services, Inc. (Pitkin County)
682
832
12
29
Delta County Health and Human Services
551
709
4
10
Denver Health and Hospitals, Community Health
801
4,714
n.a.*
30
2,597
7,870
n.a.*
22
621
503
18
34
4,982
3,448
8
14
902
1,096
2
10
4,021
3,346
9
18
236
255
6
21
Denver Health and Hospitals, Denver Metro Health Clinic Eagle County Health and Human Services El Paso County Department of Health and Environment Gunnison County Public Health Jefferson County Department of Health and Environment Kit Carson County Health and Human Services Lake County Public Health Nursing Service
292
351
11
17
Larimer County Department of Health and Environment
4,939
4,018
4
13
Mesa County Health Department
4,104
4,611
5
13
Montrose Health and Human Services
1,016
1,053
4
12
Northeast Colorado Health Department
1,651
1,459
1
15
659
1,043
6
34
Northwest Colorado Visiting Nurses Association Pueblo City-County Health Department
1,123
2,026
3
16
Rio Blanco County Nursing Service
207
196
7
9
San Juan Basin Health Department
1,061
1,482
5
17
San Miguel County Public Health Nursing Service
442
241
6
15
Spanish Peaks Regional Health Center
471
690
6
14
1,848
1,996
7
23
224
297
2
11
Tri-County Health Department
7,480
8,361
6
14
Weld County Department of Public Health and Environment
2,007
2,241
10
24
48,192
63,721
6
21
Summit Community Care Clinic Teller County Public Health
Total All Sites
*Data not available Source: Integrated Registration Information System II (IRIS) and Quarterly Tracking Reports, FY 08 - FY 12 Note: The total number of clients includes all patients, male and female. The percent of contraceptors using LARC methods is based on the number of female clients minus the number who are not using a method of contraception, e.g., those desiring pregnancy.
LARC methods would be less likely to give birth nine or more months later (i.e., in 2010 or later) than if they had used less effective or no contraception. It was anticipated that fertility rates among Title X LARC users would be reduced, and that rates among low-income women would therefore decline. In addition, the economic recession beginning in late 2008 could have heightened client motivation to delay pregnancy, and clinics were able to meet the demand for effective, longacting contraception regardless of client ability to pay.
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FIGURE 3: Actual and expected age-specific fertility rates among low-income women in all counties with CFPI agencies, 2007-2011
Figure 3 shows that the fertility rates observed in 2010 and 2011 were in fact lower than the rates that were expected based on the trends for 2007 to
150 Births per 1,000 women
2009. For women ages 15-19, the 2010 rate was 80 120
94
instead of 94, and the 2011 rate was 67 instead of
95
95. For women ages 20-24 the 2010 rate was 125
90
91
instead of 129 and the 2011 rate was 110 instead
93
91
80
60
of 128. For women ages 25-29 the 2010 rate was
67
Ages 15-19
130 instead of 134, and the 2011 rate was 125
30
instead of 131. The rates were significantly 0 2007
2008
2009
2010
2011
129
128
different from expected levels for ages 15-19 and 20-24 in 20103 and for all age groups in 2011.4
Births per 1,000 women
150 120
131
130
129
An estimated 1,000 fewer births occurred statewide among low-income women in the
125
combined age group 15 to 29 in 2010 compared
110
90
to the expected number (a 5.5 percent difference),
60
and an estimated 2,700 fewer births occurred the
Ages 20-24
following year in 2011 (a 14.6 percent difference).
30
These births were to women whose incomes would
0
likely have qualified them for Medicaid coverage of 2007
2008
2009
Births per 1,000 women
2011
134
131
130
125
prenatal care and delivery. At a cost of $7,177 in claims associated with births in 2010 and $7,085
150 120
2010
141
136
136
in 20115, a total of $26.3 million was evidently averted by the Medicaid program over the two years. Furthermore, by improving access to the
90
best contraceptive options, CFPI enabled many women in the target population avoid the
60
Ages 25-29
numerous health, social and economic
30
consequences related to unintended pregnancy.
0 2007
2008
2009
2010
2011 3
Expected Actual
p<.001 (15-19); p<0.02 (20-24); z-test for proportional differences. 4 P<.001; z test for proportional differences. 5 Medicaid paid claims from Medicaid Management Information Systems-Decision Support System for Fiscal Year 2010-2011 and 2011-2012 for deliveries and associated gestational/postpartum expenditures.
4
Conclusion The Colorado Family Planning Initiative was designed to increase the number of clients served through Title X agencies and to increase the percentage of users of long-acting reversible contraceptives. Prior to CFPI, existing funding could not support wide scale purchase of LARC methods at Title X clinics due to their high initial cost. This state of affairs created an access barrier for many low-income and uninsured women. CFPI funding allowed clinics to provide more client-centered care, ensuring that LARC methods could be stocked for use at any given time and available to individuals desiring the most effective contraceptives. The number of clients served increased by one-third in four years, and the percentage of contraceptors using LARC methods quadrupled. At the same time, fertility rates in the age and low-income groups targeted by the agencies fell significantly. By 2011, an estimated 3,700 fewer births had occurred among lowincome women ages 15-29 compared to the number that would have been expected. The Colorado Family Planning Initiative allowed clients easy access to effective, long-acting contraceptives that were previously unaffordable. By changing the choices available to clients, CFPI enabled women to confidently avoid unintended pregnancies.
5