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.

Recommendations and Reports / Vol. 63 / No. 4 April 25, 2014

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

Morbidity and Mortality Weekly Report

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Recommendations and Reports

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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

Christine G. Casey, MD, Editor

Teresa F. Rutledge, Managing Editor

David C. Johnson, Lead Technical Writer-Editor

Jeffrey D. Sokolow, MA, Project Editor

Martha F. Boyd, Lead Visual Information Specialist

Maureen A. Leahy, Julia C. Martinroe,

Stephen R. Spriggs, Terraye M. Starr

Visual Information Specialists

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

Virginia A. Caine, MD, Indianapolis, IN

Barbara A. Ellis, PhD, MS, Atlanta, GA

Jonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA

David W. Fleming, MD, Seattle, WA

William E. Halperin, MD, DrPH, MPH, Newark, NJ

King K. Holmes, MD, PhD, Seattle, WA

Timothy F. Jones, MD, Nashville, TN

Rima F. Khabbaz, MD, Atlanta, GA

Dennis G. Maki, MD, Madison, WI

Patricia Quinlisk, MD, MPH, Des Moines, IA

Patrick L. Remington, MD, MPH, Madison, WI

William Schaffner, MD, Nashville, TN

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

Appendix B

........................................................................................................... 35

Appendix C

........................................................................................................... 45

Appendix D

........................................................................................................... 47

Appendix E............................................................................................................ 48

Appendix F............................................................................................................ 51

Recommendations and Reports

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

Providing Quality Family Planning Services

Recommendations of CDC and the U.S. Office of Population Affairs

Prepared by

Loretta Gavin, PhD,

Susan Moskosky, MS,

Marion Carter, PhD,

Kathryn Curtis, PhD,

Evelyn Glass, MSPH,

Emily Godfrey,

MD,

Arik Marcell, MD,

Nancy Mautone-Smith, MSW,

Karen Pazol, PhD,

Naomi Tepper, MD,

Lauren Zapata, PhD

Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC

Office of Population Affairs, US Department of Health and Human Services, Rockville, Maryland

The 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.

Corresponding preparers: Loretta Gavin, PhD, Division of Reproductive

Health, National Center for Chronic Disease Prevention and Health

Promotion, CDC. Telephone: 770-488-6284; E-mail: lcg6@cdc.gov;

Susan Moskosky, MS, Office of Population Affairs, US Department of

Health and Human Services. Telephone: 240-453-2818; E-mail:

[email protected].

Introduction

The United States continues to face challenges to improving

the reproductive health of the U.S. population. Nearly half (49%)

of all pregnancies are unintended (1). Although adolescent birth

rates declined by more than 61% during 1991–2012, the United

States has one of the highest adolescent pregnancy rates in the

developed world, with >700,000 adolescents aged 15–19 years

becoming pregnant each year and >300,000 giving birth (2,3).

Approximately one of eight pregnancies in the United States

results in a preterm birth, and infant mortality rates remain high

compared with other developed countries (3,4). Moreover, all

of these outcomes affect racial and ethnic minority populations

disproportionately (1–4).

Family planning services can help address these and other public

health challenges by providing education, counseling, and medical

services (5). Family planning services include the following:

• providing contraception to help women and men plan

and space births, prevent unintended pregnancies, and

reduce the number of abortions;

• offering pregnancy testing and counseling;

• helping clients who want to conceive;

• providing basic infertility services;

• providing preconception health services to improve infant

and maternal outcomes and improve women’s and men’s

health; and

• providing sexually transmitted disease (STD) screening

and treatment services to prevent tubal infertility and

improve the health of women, men, and infants.

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 family

planning services by:

Recommendations and Reports

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

• defining a core set of family planning services for women

and men,

• describing how to provide contraceptive and other clinical

services, serve adolescents, and perform quality

improvements, and

• encouraging 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 (IOM) and adopted by HHS (6).

The collaboration between CDC and OPA drew on the

strengths of both agencies. CDC has a long-standing history of

developing evidence-based recommendations for clinical care,

and OPA’s Title X Family Planning Program (7) has served as

the national leader in direct family planning service delivery

since the Title X program was established in 1970.

This report provides recommendations for providing care to

clients of reproductive age who are in need of family planning

services. These recommendations are intended for all current

or potential providers of family planning services, including

those funded by the Title X program.

Current Context of Family

Planning Services

Women of reproductive age often report that their family

planning provider is also their usual source of health care (8).

As the U.S. health-care system evolves in response to increased

efforts to expand health insurance coverage, contain costs, and

emphasize preventive care (9), providers of family planning

services will face new challenges and opportunities in care

delivery. For example, they will have increased opportunities

to serve new clients and to serve as gateways for their clients to

other essential health-care services. In addition, primary care

and other providers who provide a range of health-care services

will be expected to integrate family planning services for all

persons of reproductive age, including those whose primary

reason for their health-care visit might not be family planning.

Strengthened, multidirectional care coordination also will be

needed to improve health outcomes. For example, this type

of care coordination will be needed with clients referred to

specialist care after initial screening at a family planning visit,

as well as with specialists referring clients with family planning

needs to family planning providers.

Defining Quality in Family

Planning Service Delivery

The central premise underpinning these recommendations

is that improving the quality of family planning services will

lead to improved reproductive health outcomes (10–12). IOM

defines health-care quality as the extent to which health-care

services improve health outcomes in a manner that is consistent

with current professional knowledge (10,13). According to

IOM, quality health care has the following attributes:

• Safety. These recommendations integrate other CDC

recommendations about which contraceptive methods can

be provided safely to women with various medical

conditions, and integrate CDC and U.S. Preventive

Services Task Force (USPSTF) recommendations on STD,

preconception, and related preventive health services.

• Effectiveness. These recommendations support offering

a full range of Food and Drug Administration

(FDA)–approved contraceptive methods as well as

counseling that highlights the effectiveness of contraceptive

methods overall and, in specific patient situations, draws

attention to the effectiveness of specific clinical preventive

health services and identifies clinical preventive health

services for which the potential harms outweigh the

benefits (i.e., USPSTF “D” recommendations).

• Client-centered approach. These recommendations

encourage taking a client-centered approach by

1) highlighting that the client’s primary purpose for

visiting the service site must be respected, 2) noting the

importance of confidential services and suggesting ways

to provide them, 3) encouraging the availability of a broad

range of contraceptive methods so that clients can make

a selection based on their individual needs and preferences,

and 4) reinforcing the need to deliver services in a

culturally competent manner so as to meet the needs of

all clients, including adolescents, those with limited

English proficiency, those with disabilities, and those who

are lesbian, gay, bisexual, transgender, or questioning their

sexual identity (LGBTQ). Organizational policies,

governance structures, and individual attitudes and

practices all contribute to the cultural competence of a

health-care entity and its staff. Cultural competency within

a health-care setting refers to attitudes, practices, and

policies that enable professionals to work effectively in

cross-cultural situations (14–16).

• Timeliness. These recommendations highlight the

importance of ensuring that services are provided to clients

in a timely manner.

• Efficiency. These recommendations identify a core set of

services that providers can focus on delivering, as well as

ways to maximize the use of resources.

• Accessibility. These recommendations address how to

remove barriers to contraceptive use, use the family planning

visit to provide access to a broader range of primary care

and behavioral health services, use the primary care visit to

Recommendations and Reports

MMWR / April 25, 2014 / Vol. 63 / No. 4 3

provide access to contraceptive and other family planning

services, and strengthen links to other sources of care.

• Equity. These recommendations highlight the need for

providers of family planning services to deliver high-

quality care to all clients, including adolescents, LGBTQ

persons, racial and ethnic minorities, clients with limited

English proficiency, and persons living with disabilities.

• Value. These recommendations highlight services (i.e.,

contraception and other clinical preventive services) that

have been shown to be very cost-effective (17–19).

Methods

Recommendations Development Process

The recommendations were developed jointly under the

auspices of CDC’s Division of Reproductive Health and

OPA, in consultation with a wide range of experts and key

stakeholders. More information about the processes used to

conduct systematic reviews, the role of technical experts in

reviewing the evidence, and the process of using the evidence

to develop recommendations is provided (Appendix A). A

multistage process was used to develop the recommendations

that drew on established procedures for developing clinical

guidelines (20,21). First, an Expert Work Group* was formed

comprising family planning clinical providers, program

administrators, and representatives from relevant federal

agencies and professional medical associations to help define

the scope of the recommendations. Next, literature about

three priority topics (i.e., counseling and education, serving

adolescents, and quality improvement) was reviewed by using

the USPSTF methodology for conducting systematic reviews

(22). The results were presented to three technical panels

†

comprising subject matter experts (one panel for each priority

topic) who considered the quality of the evidence and made

suggestions for what recommendations might be supported on

the basis of the evidence. In a separate process, existing clinical

recommendations on women’s and men’s preventive services

were compiled from more than 35 federal and professional

medical associations, and these results were presented to two

technical panels of subject matter experts, one that addressed

women’s clinical services and one that addressed men’s clinical

services. The panels provided individual feedback about

which clinical preventive services should be offered in a family

planning setting and which clinical recommendations should

receive the highest consideration.

CDC and OPA used the input from the subject matter

experts to develop a set of core recommendations and asked

the Expert Work Group to review them. The members of

the Expert Work Group were more familiar with the family

planning service delivery context than the members of the

Technical Panel and thus could better comment on the

feasibility and appropriateness of the recommendations,

as well as the supporting evidence. The Expert Work

Group considered the core recommendations by using the

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,

and implementation challenges; and 3) the relative importance

of these consequences, (e.g., the likelihood that implementation

of the recommendation will have a substantial effect on health

outcomes might be considered more than the logistical

challenges of implementing it) (20). In certain cases, when

the evidence from the literature reviews was inconclusive or

incomplete, recommendations were made on the basis of expert

opinion. Finally, CDC and OPA staff considered the individual

feedback from Expert Work Group members when finalizing

the core recommendations and writing the recommendations

document. A description of how the recommendations link

to the evidence is provided together with the rationale for the

inclusion of each recommendation in this report (Appendix B).

The evidence used to prepare these recommendations

will appear in background papers that will be published

separately. Resources that will help providers implement the

recommendations will be provided through a web-based tool

kit that will be available at http://www.hhs.gov/opa.

Audience for the Recommendations

The primary audience for this report is all providers or

potential providers of family planning services to clients of

reproductive age, including providers working in clinics that

are dedicated to family planning service delivery, as well as

private and public providers of more comprehensive primary

care. Providers of dedicated family planning services might be

less familiar with the specific recommendations for the delivery

of preconception services. Providers of more comprehensive

primary care might be less familiar with the delivery of

contraceptive services, pregnancy testing and counseling, and

services to help clients achieve pregnancy.

This report can be used by medical directors to write clinical

protocols that describe how care should be provided. Job aids

and other resources for use in service sites are being developed

and will be made available when ready through OPA’s website

(http://www.hhs.gov/opa).

* A list of the members of the Expert Work Group appears on page 52.

†

A list of the members of the technical panels appears on pages 52 and 53.

Recommendations and Reports

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

In this report, the term “provider” refers to any staff member

who is involved in providing family planning services to a

client. This includes physicians, physician assistants, nurse

practitioners, nurse-midwives, nursing staff, and health

educators. The term “service site” represents the numerous

settings in which family planning services are delivered, which

include freestanding service sites, community health centers,

private medical facilities, and hospitals. A list of special terms

used in this report is provided (Box 1).

The recommendations are designed to guide general clinical

practice; however, health-care providers always should consider

the individual clinical circumstances of each person seeking

family planning services. Similarly, these recommendations

might need to be adapted to meet the needs of particular

populations, such as clients who are HIV-positive or who are

substance users.

Organization of the Recommendations

This report is divided into nine sections. An initial section

provides an overview of steps to assess the needs of a client

and decide what family planning services to offer. Subsequent

sections describe how to provide each of the following services:

contraceptive services, pregnancy testing and counseling, helping

clients achieve pregnancy, basic infertility services, preconception

health services, STD services and related preventive health services.

A final section on quality improvement describes actions that all

providers of family planning services should consider to ensure

that services are of high quality. More detailed information about

selected topics addressed in the recommendations is provided

(Appendices A–F).

These recommendations focus on the direct delivery of care

to individual clients. However, parallel steps might need to be

taken to maintain the systems required to support the provision of

quality services for all clients (e.g., record-keeping procedures that

preserve client confidentiality, procedures that improve efficiency

and reduce clients’ wait time, staff training to ensure that all clients

are treated with respect, and the establishment and maintenance

of a strong system of care coordination and referrals).

Client Care

Family planning services are embedded within a broader

framework of preventive health services (Figure 1). In this

report, health services are divided into three main categories:

• Family planning services. These include contraceptive

services for clients who want to prevent pregnancy and space

births, pregnancy testing and counseling, assistance to achieve

pregnancy, basic infertility services, STD services (including

HIV/AIDS), and other preconception health services (e.g.,

screening for obesity, smoking, and mental health). STD/HIV

and other preconception health services are considered family

planning services because they improve women’s and men’s

health and can influence a person’s ability to conceive or to

have a healthy birth outcome.

• Related preventive health services. These include services

that are considered to be beneficial to reproductive health,

BOX 1. Definitions of quality terms used in this report

Accessible. The timely use of personal health services

to achieve the best possible health outcomes.*

Client-centered. Care is respectful of, and responsive

to, individual client preferences, needs, and values; client

values guide all clinical decisions.

†

Effective. Services are based on scientific knowledge and

provided to all who could benefit and are not provided to

those not likely to benefit.

†

Efficient. Waste is avoided, including waste of equipment,

supplies, ideas, and energy.

†

Equitable. Care does not vary in quality because of the

personal characteristics of clients (e.g., sex, race/ethnicity,

geographic location, insurance status, or socioeconomic

status).

†

Evidence-based. The process of integrating science-

based interventions with community preferences to

improve the health of populations.

Health-care quality. The degree to which health-care

services for individuals and populations increase the

likelihood of desired health outcomes and are consistent

with current professional knowledge.

†

Process. Whether services are provided correctly and

completely and how clients perceive the care they receive.

Safe. Avoids injuries to clients from the care that is

intended to help them.

†

Structure. The characteristics of the settings in which

providers deliver health care, including material resources,

human resources, and organizational structure.

Timely. Waits and sometimes harmful delays for both

those who receive and those who provide care are reduced.

†

Value. The care provides good return relative to the costs

involved, such as a return on investment or a reduction in

the per capita cost of health care.*

* Source: Institute of Medicine. Future directions for the national healthcare

quality and disparities reports. Ulmer C, Bruno M, Burke S, eds.

Washington, DC: The National Academies Press; 2010.

†

Source: Institute of Medicine. Crossing the quality chasm: a new health

system for the 21st century. Committee on Quality of Health Care in

America, ed. Washington, DC: National Academies of Science; 2001.

Source: Kohatsu ND, Robinson JG, Torner JC. Evidence-based public

health: an evolving concept. Am J Prev Med 2004;27:417–21.

Source: Donabedian A. The quality of care. JAMA 1988;260:1743–8.

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MMWR / April 25, 2014 / Vol. 63 / No. 4 5

are closely linked to family planning services, and are

appropriate to deliver in the context of a family planning visit

but that do not contribute directly to achieving or preventing

pregnancy (e.g., breast and cervical cancer screening).

• Other preventive health services. These include

preventive health services for women that were not

included above (6), as well as preventive services for men.

Screening for lipid disorders, skin cancer, colorectal cancer,

or osteoporosis are examples of this type of service.

Although important in the context of primary care, these

have no direct link to family planning services.

Providers of family planning services should be trained and

equipped to offer all family planning and related preventive

health services so that they can provide optimal care to clients,

with referral for specialist care, as needed. Other preventive

health services should be available either on-site or by referral,

but these recommendations do not address this category

of services. Information about preventive services that are

beyond the scope of this report is available at http://www.

uspreventiveservicestaskforce.org.

Determining the Client’s Need for Services

These recommendations apply to two types of encounters

with women and men of reproductive age. In the first type of

encounter, the primary reason for a client’s visit to a health-

care provider is related to preventing or achieving pregnancy,

(i.e., contraceptive services, pregnancy testing and counseling,

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

pregnancy, providers should assess whether the client needs

other related services and offer them to the client. In the second

type of encounter, the primary reason for a client’s visit to a

health-care provider is not related to preventing or achieving

pregnancy. For example, the client might come in for acute

care (e.g., a male client coming in for STD symptoms or as

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

assess the client’s need for services related to preventing or

achieving pregnancy.

A clinical pathway of family planning services for women and

men of reproductive age is provided (Figure 2). The following

questions can help providers determine what family planning

services are most appropriate for a given visit.

• 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

of primary care for a client will help identify what

preventive services a provider should offer. If a provider is

the client’s main source of primary care, it will be

important to assess the client’s needs for the other services

listed in this report. If the client receives ongoing primary

care from another provider, the provider should confirm

that the client’s preventive health needs are met while

avoiding the delivery of duplicative services.

• What is the client’s reproductive life plan? An assessment

should be made of the client’s reproductive life plan, which

outlines personal goals about becoming pregnant (23–25)

(Box 2).The provider should avoid making assumptions

about the client’s needs based on his or her characteristics,

such as sexual orientation or disabilities. For clients whose

initial reason for coming to the service site was not related to

preventing or achieving pregnancy, asking questions about

his or her reproductive life plan might help identify unmet

reproductive health-care needs. Identifying a need for

contraceptive services might be particularly important given

the high rate of unintended pregnancy in the United States.

– If the client does not want a child at this time and is

sexually active, then offer contraceptive services.

– If the client desires pregnancy testing, then provide

pregnancy testing and counseling.

– If the client wants to have a child now, then provide

services to help the client achieve pregnancy.

FIGURE 1. Family planning and related and other preventive health

services

Family planning services

• Contraceptive services

• Pregnancy testing and

counseling

• Achieving pregnancy

• Basic infertility services

• Preconception health

• Sexually transmitted

disease services

Related preventive

health services

(e.g., screening for breast

and cervical cancer)

Other preventive

health services

(e.g., screening for lipid

disorders)

Recommendations and Reports

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

– If the client wants to have a child and is experiencing

difficulty conceiving, then provide basic infertility services.

• Does the client need preconception health services?

Preconception health services (such as screening for

obesity, smoking, and mental health) are a subset of all

preventive services for women and men. Preconception

health care is intended to promote the health of women

and men of reproductive age before conception, with the

goal of improving pregnancy-related outcomes (24).

Preconception health services are also important because

they improve the health of women and men, even if they

choose not to become pregnant. The federal and

professional medical recommendations cited in this report

should be followed when determining which preconception

health services a client might need.

• Does the client need STD services? The need for STD

services, including HIV/AIDS testing, should be considered

at every visit. Many clients requesting contraceptive services

also might meet the criteria for being at risk of one or more

STDs. Screening for chlamydia and gonorrhea is especially

important in a family planning context because these STDs

contribute to tubal infertility if left untreated. STD services

are also necessary to maximize preconception health. The

federal recommendations cited in this report should be

followed when determining which STD services a client

might need. Aspects of managing symptomatic STDs are

not addressed in these recommendations.

• What other related preventive health services does the

client need? Whether the client needs related preventive

health services, such as breast and cervical cancer screening

for female clients, should be assessed. The federal and

professional medical recommendations cited in this report

should be followed when determining which related

preventive health services a client might need.

FIGURE 2. Clinical pathway of family planning services for women and men of reproductive age

Reason for visit is related to

preventing or achieving

pregnancy

Initial reason for visit is not

related to preventing or

achieving pregnancy

• Acute care

• Chronic care management

• Preventive services

If services are not needed at this

visit, reassess at subsequent visits

If needed,

provide

services

Contraceptive

services

Pregnancy

testing and

counseling

Achieving

pregnancy

Basic

infertility

services

Sexually

transmitted

disease

services

Preconception

health

services

preventive

health

services

Clients also should be

provided these

services, per

clinical recommendations

Clients

also should

be provided

or referred for these services,

per clinical recommendations

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

Assess need for services related

to preventing or achieving

pregnancy

Recommendations and Reports

MMWR / April 25, 2014 / Vol. 63 / No. 4 7

The individual client’s needs should be considered when

determining what services to offer at a given visit. It might not

be feasible to deliver all the needed services in a single visit, and

they might need to be delivered over the course of several visits.

Providers should tailor services to meet the specific needs of

the population they serve. For example, clients who are trying

to achieve pregnancy and those at high risk of unintended

pregnancy should be given higher priority for preconception

health services. In some cases, the provider will deliver the

initial screening service but then refer to another provider for

further diagnosis or follow-up care.

The delivery of preconception, STD, and related preventive

health services should not become a barrier to a client’s ability

to receive services related to preventing or achieving pregnancy.

For these clients, receiving services related to preventing or

achieving pregnancy is the priority; if other family planning

services cannot be delivered at the initial visit, then follow-up

visits should be scheduled.

In addition, professional recommendations for how to

address the needs of diverse clients, such as LGBTQ persons

(26–32) or persons with disabilities (33), should be consulted

and integrated into procedures, as appropriate. For example,

as noted before, providers should avoid making assumptions

about a client’s gender identity, sexual orientation, race,

or ethnicity; all requests for services should be treated

without regard to these characteristics. Similarly, services for

adolescents should be provided in a “youth-friendly” manner,

which means that they are accessible, equitable, acceptable,

appropriate, comprehensive, effective, and efficient for youth,

as recommended by the World Health Organization (34).

Contraceptive Services

Providers should offer contraceptive services to clients who

wish to delay or prevent pregnancy. Contraceptive services

should include consideration of a full range of FDA-approved

contraceptive methods, a brief assessment to identify the

contraceptive methods that are safe for the client, contraceptive

counseling to help a client choose a method of contraception

and use it correctly and consistently, and provision of one or

more selected contraceptive method(s), preferably on site, but

by referral if necessary. Contraceptive counseling is defined as

a process that enables clients to make and follow through on

decisions about their contraceptive use. Education is an integral

component of the contraceptive counseling process that helps

clients to make informed decisions and obtain the information

they need to use contraceptive methods correctly.

Key steps in providing contraceptive services, including

contraceptive counseling and education, have been outlined

(Box 3). These key steps are in accordance with the five principles

of quality counseling (Appendix C). To help a client who is

initiating or switching to a new method of contraception,

providers should follow these steps. These steps most likely will

be implemented iteratively when working with a client and

should help clients adopt, change, or maintain contraceptive use.

Step 1. Establish and maintain rapport with the client.

Providers should strive to establish and maintain rapport.

Strategies to achieve these goals include the following:

• using open-ended questions;

• demonstrating expertise, trustworthiness, and accessibility;

• ensuring privacy and confidentiality;

• explaining how personal information will be used;

• encouraging the client to ask questions and share

information;

• listening to and observing the client; and

• being encouraging and demonstrating empathy and

acceptance.

Step 2. Obtain clinical and social information from

the client. Providers should ask clients about their medical

history to identify methods that are safe. In addition, to learn

more about factors that might influence a client’s choice of a

contraceptive method, providers should confirm the client’s

pregnancy intentions or reproductive life plan, ask about the

client’s contraceptive experiences and preferences, and conduct

a sexual health assessment. When available, standardized tools

should be used.

• Medical history. A medical history should be taken to

ensure that methods of contraception being considered

by a client are safe for that particular client. For a female

client, the medical history should include menstrual

history (including last menstrual period, menstrual

frequency, length and amount of bleeding, and other

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

reproductive life plan

Providers should discuss a reproductive life plan with

clients receiving contraceptive, pregnancy testing and

counseling, basic infertility, sexually transmitted disease,

and preconception health services in accordance with

CDC’s recommendation that all persons capable of having

a child should have a reproductive life plan.*

Providers should assess the client’s reproductive life plan

by asking the client questions such as:

• Do you have any children now?

• Do you want to have (more) children?

• How many (more) children would you like to have

and when?

* Source: CDC. Recommendations to improve preconception health and

health care—United States: a report of the CDC/ATSDR Preconception

Care Work Group and the Select Panel on Preconception Care. MMWR

2006;55(No. RR-6).

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

patterns of uterine/vaginal bleeding), gynecologic and

obstetrical history, contraceptive use, allergies, recent

intercourse, recent delivery, miscarriage, or termination,

and any relevant infectious or chronic health condition

and other characteristics and exposures (e.g., age,

postpartum, and breastfeeding) that might affect the

client’s medical eligibility criteria for contraceptive

methods (35). Clients considering combined hormonal

contraception should be asked about smoking tobacco, in

accordance with CDC guidelines on contraceptive use

(35). Additional details about the methods of contraception

that are safe to use for female clients with specific medical

conditions and characteristics (e.g., hypertension) are

addressed in previously published guidelines (35). For a

male client, a medical history should include use of

condoms, known allergies to condoms, partner use of

contraception, recent intercourse, whether his partner is

currently pregnant or has had a child, miscarriage, or

termination, and the presence of any infectious or chronic

health condition. However, the taking of a medical history

should not be a barrier to making condoms available in

the clinical setting (i.e., a formal visit should not be a

prerequisite for a client to obtain condoms).

• Pregnancy intention or reproductive life plan. Each

client should be encouraged to clarify decisions about her

or his reproductive life plan (i.e., whether the client wants

to have any or more children and, if so, the desired timing

and spacing of those children) (24).

• Contraceptive experiences and preferences. Method-

specific experiences and preferences should be assessed by

asking questions such as, “What method(s) are you

currently using, if any?”; “What methods have you used

in the past?”; “Have you previously used emergency

contraception?”; “Did you use contraception at last sex?”;

“What difficulties did you experience with prior methods

if any (e.g., side effects or noncompliance)?”; “Do you

have a specific method in mind?”; and “Have you discussed

method options with your partner, and does your partner

have any preferences for which method you use?” Male

clients should be asked if they are interested in vasectomy.

• Sexual health assessment. A sexual history and risk

assessment that considers the client’s sexual practices,

partners, past STD history, and steps taken to prevent

STDs (36) is recommended to help the client select the

most appropriate method(s) of contraception. Correct and

consistent condom use is recommended for those at risk

for STDs. CDC recommendations for how to conduct a

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

should work with the client interactively to select an effective

and appropriate contraceptive method. Specifically, providers

should educate the client about contraceptive methods that

the client can safely use, and help the client consider potential

barriers to using the method(s) under consideration. Use of

decision aids (e.g., computerized programs that help a client

to identify a range of methods that might be appropriate for

the client based on her physical characteristics such as health

conditions or preferences about side effects) before or while

waiting for the appointment can facilitate and maximize the

utility of the time spent on this step.

Providers should inform clients about all contraceptive

methods that can be used safely. Before the health-care visit,

clients might have only limited information about all or

specific methods of contraception (37). A broad range of

methods, including long-acting reversible contraception (i.e.,

intrauterine devices [IUDs] and implants), should be discussed

with all women and adolescents, if medically appropriate.

Providers are encouraged to present information on potential

reversible methods of contraception by using a tiered approach

(i.e., presenting information on the most effective methods first,

before presenting information on less effective methods) (38,39).

This information should include an explanation that long-

acting reversible contraceptive methods are safe and effective for

most women, including those who have never given birth and

adolescents (35). Information should be tailored and presented

to ensure a client-centered approach. It is not appropriate to omit

presenting information on a method solely because the method

is not available at the service site. If not all methods are available

at the service site, it is important to have strong referral links in

place to other providers to maximize opportunities for clients

to obtain their preferred method that is medically appropriate.

BOX 3. Steps in providing contraceptive services, including

contraceptive counseling* and education

• Establish and maintain rapport with the client.

• Obtain clinical and social information from the client.

• Work with the client interactively to select the most

effective and appropriate contraceptive method.

• Conduct a physical assessment related to

contraceptive use, only when warranted.

• Provide the contraceptive method along with

instructions about correct and consistent use, help the

client develop a plan for using the selected method

and for follow up, and confirm client understanding.

* Key principles of providing quality counseling including education have

been outlined (Appendix C).

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MMWR / April 25, 2014 / Vol. 63 / No. 4 9

For clients who have completed childbearing or do not plan

to have children, permanent sterilization (female or male) is an

option that may be discussed. Both female and male sterilization

are safe, are highly effective, and can be performed in an office

or outpatient surgery setting (40,41). Women and men should

be counseled that these procedures are not intended to be

reversible and that other highly effective, reversible methods of

contraception (e.g., implants or IUDs) might be an alternative

if they are unsure about future childbearing. Clients interested

in sterilization should be referred to an appropriate source of

care if the provider does not perform the procedure.

When educating clients about contraceptive methods that

the clients can use safely, providers should ensure that clients

understand the following:

• Method effectiveness. A contraceptive method’s rate of

typical effectiveness, or the percentage of women

experiencing an unintended pregnancy during the first

year of typical use, is an important consideration (Figure 3;

Appendix D) (38,42).

• Correct use of the method. The mode of administration

and understanding how to use the method correctly might

be important considerations for the client when choosing

a method. For example, receiving a contraceptive injection

every 3 months might not be acceptable to a woman who

fears injections. Similarly, oral contraceptives might not

be acceptable to a woman who is concerned that she might

not be able to remember to take a pill every day.

• Noncontraceptive benefits. Many contraceptives have

noncontraceptive benefits, in addition to preventing

pregnancy, such as reducing heavy menstrual bleeding.

Although the noncontraceptive benefits are not generally

the major determinant for selecting a method, awareness

of these benefits can help clients decide between two or

more suitable methods and might enhance the client’s

motivation to use the method correctly and consistently.

• Side effects. Providers should inform the client about risks

and side effects of the method(s) under consideration, help

the client understand that certain side effects of contraceptive

methods might disappear over time, and encourage the

client to weigh the experience of coping with side effects

against the experience and consequences of an unintended

pregnancy. The provider should be prepared to discuss and

correct misperceptions about side effects. Clients also should

be informed about warning signs for rare, but serious,

adverse events with specific contraceptive methods, such as

stroke and venous thromboembolism with use of combined

hormonal methods.

• Protection from STDs, including HIV. Clients should

be informed that contraceptive methods other than

condoms offer no protection against STDs, including

HIV. Condoms, when used correctly and consistently,

help reduce the risk of STDs, including HIV, and provide

protection against pregnancy. Dual protection (i.e.,

protection from both pregnancy and STDs) is important

for clients at risk of contracting an STD, such as those

with multiple or potentially infected partner(s). Dual

protection can be achieved through correct and consistent

use of condoms with every act of sexual intercourse, or

correct and consistent use of a condom to prevent infection

plus another form of contraception to prevent pregnancy.

(For more information about preventing and treating

STDs, see STD Services.)

When educating clients about the range of contraceptive

methods, providers should ensure that clients have information

that is medically accurate, balanced, and provided in a

nonjudgmental manner. To assist clients in making informed

decisions, providers should educate clients in a manner that

can be readily understood and retained. The content, format,

method, and medium for delivering education should be

evidence-based (see Appendix E).

When working with male clients, when appropriate, providers

should discuss information about female-controlled methods

BOX 4. Steps in conducting a sexual health assessment*

• Practices: Explore the types of sexual activity in which

the patient engages (e.g., vaginal, anal, or oral sex).

• Pregnancy prevention: Discuss current and future

contraceptive options. Ask about current and previous

use of methods, use of contraception at last sex,

difficulties with contraception, and whether the client

has a particular method in mind.

• Partners: Ask questions to determine the number, gender

(men, women, or both), and concurrency of the patient’s

sex partners (if partner had sex with another partner while

still in a sexual relationship with the patient). It might be

necessary to define the term “partner” to the patient or use

other, relevant terminology.

• Protection from sexually transmitted diseases

(STDs): Ask about condom use, with whom they do

or do not use condoms, and situations that make it

harder or easier to use condoms. Topics such as

monogamy and abstinence also can be discussed.

• Past STD history: Ask about any history of STDs,

including whether their partners have ever had an

STD. Explain that the likelihood of an STD is higher

with a past history of an STD.

* Source: CDC. Sexually transmitted diseases treatment guidelines, 2010.

MMWR 2010;59(No. RR-12).

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

(including emergency contraception) encourage discussion of

contraception with partners, and provide information about how

partners can access contraceptive services. Male clients should

also be reminded that condoms should be used correctly and

consistently to reduce risk of STDs, including HIV.

When working with any client, encourage partner

communication about contraception, as well as understanding

partner barriers (e.g., misperceptions about side effects) and

facilitators (e.g., general support) of contraceptive use (43–46).

The provider should help the client consider potential

barriers to using the method(s) under consideration. This

includes consideration of the following factors:

• Social-behavioral factors. Social-behavioral factors might

influence the likelihood of correct and consistent use of

contraception (47). Providers should help the client

consider the advantages and disadvantages of the

method(s) being considered, the client’s feelings about

using the method(s), how her or his partner is likely to

respond, the client’s peers’ perceptions of the method(s),

and the client’s confidence in being able to use the method

correctly and consistently (e.g., using a condom during

every act of intercourse or remembering to take a pill every

day) (37).

• Intimate partner violence and sexual violence. Current

and past intimate partner sexual or domestic violence

might impede the correct and consistent use of

contraception, and might be a consideration when

choosing a method (47–49). For example, an IUD might

FIGURE 3. The typical effectiveness of Food and Drug Administration–approved contraceptive methods

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MMWR / April 25, 2014 / Vol. 63 / No. 4 11

be preferred because it does not require the partner’s

participation. The medical history might provide

information on signs of current or past violence and, if

not, providers should ask clients about relationship issues

that might be potential barriers to contraceptive use. In

addition, clients experiencing intimate partner violence

or sexual violence should be referred for appropriate care.

• Mental health and substance use behaviors. Mental health

(e.g., depression, anxiety disorders, and other mental

disorders) and substance use behaviors (e.g., alcohol use,

prescription abuse, and illicit drug use) might affect a client’s

ability to correctly and consistently use contraception

(47,50). The medical history might provide information

about the signs of such conditions or behaviors, and if not,

providers should ask clients about substance use behaviors

or mental health disorders, such as depression or anxiety,

that might interfere with the motivation or ability to follow

through with contraceptive use. If needed, clients with

mental health disorders or risky substance use behaviors

should be referred for appropriate care.

Step 4. Conduct a physical assessment related to

contraceptive use, when warranted. Most women will need

no or few examinations or laboratory tests before starting a

method of contraception. Guidance on necessary examinations

and tests related to initiation of contraception is available (42).

A list of assessments that need to be conducted when providing

reversible contraceptive services to a female client seeking to

initiate or switch to a new method of reversible contraception is

provided (Table 1) (42). Clinical evaluation of a client electing

permanent sterilization should be guided by the clinician who

performs the procedure. Recommendations for contraceptive

use are available (42). Key points include the following:

• Blood pressure should be taken before initiating the use

of combined hormonal contraception.

• Providers should assess the current pregnancy status of

clients receiving contraception (42), which provides

guidance on how to be reasonably certain that a woman

is not pregnant at the time of contraception initiation. In

most cases, a detailed history provides the most accurate

assessment of pregnancy risk in a woman about to start

using a contraceptive method. Routine pregnancy testing

for every woman is not necessary.

• Weight measurement is not needed to determine medical

eligibility for any method of contraception because all

methods generally can be used among obese women.

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.

• Unnecessary medical procedures and tests might create

logistical, emotional, or economic barriers to contraceptive

access for some women, particularly adolescents and low-

income women, who have high rates of unintended

pregnancies (1,51,52). For both adolescent and adult

female clients, the following examinations and tests are

not needed routinely to provide contraception safely to a

healthy client (although they might be needed to address

other non-contraceptive health needs) (42):

– pelvic examinations, unless inserting an intrauterine

device (IUD) or fitting a diaphragm;

– cervical cytology or other cancer screening, including

clinical breast exam;

– human immunodeficiency virus (HIV) screening; and

– laboratory tests for lipid, glucose, liver enzyme, and

hemoglobin levels or thrombogenic mutations.

For male clients, no physical examination needs to be

performed before distributing condoms.

Step 5. Provide the contraceptive method along with

instructions about correct and consistent use, help the

client develop a plan for using the selected method and for

follow-up, and confirm client understanding.

• A broad range of FDA-approved contraceptive methods

should be available onsite. Referrals for methods not

available onsite should be provided for clients who indicate

they prefer those methods. When providing contraception,

providers should instruct the client about correct and

consistent use and employ the following strategies to

facilitate a client’s use of contraception:

– Provide onsite dispensing;

– Begin contraception at the time of the visit rather than

waiting for next menses (also known as “quick start”) if

the provider can reasonably be certain that the client is

not pregnant (42). A provider can be reasonably certain

that a woman is not pregnant if she has no symptoms or

signs of pregnancy and meets any one of the following

criteria (42,53):

ˏ is ≤7 days after the start of normal menses,

ˏ has not had sexual intercourse since the start of last

normal menses,

ˏ has been using a reliable method of contraception

correctly and consistently,

ˏ is ≤7 days after spontaneous or induced abortion,

ˏ is within 4 weeks postpartum,

ˏ is fully or nearly fully breastfeeding (exclusively

breastfeeding or the vast majority [≥85%] of feeds are

breastfeeds), amenorrheic, and <6 months postpartum;

– Provide or prescribe multiple cycles (ideally a full year’s

supply) of oral contraceptive pills, the patch, or the ring

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

to minimize the number of times a client has to return to

the service site;

– Make condoms easily and inexpensively available; and

– If a client chooses a method that is not available on-site

or the same day, provide the client another method to

use until she or he can start the chosen method.

• Help the client develop a plan for using the selected

method. Using a method incorrectly or inconsistently and

having gaps in contraceptive protection because of method

switching both increase the likelihood of an unintended

pregnancy (37). After the method has been provided, or

a plan put into place to obtain the chosen method,

providers should help the client develop an action plan

for using the selected method.

Providers should encourage clients to anticipate reasons

why they might not use their chosen method(s) correctly or

consistently, and help them develop strategies to deal with

these possibilities. For example, for a client selecting oral

contraceptive pills who might forget to take a pill, the provider

can work with the client to identify ways to routinize daily

pill taking (e.g., use of reminder systems such as daily text

messages or cell phone alarms). Providers also may inform

clients about the availability of emergency contraceptive pills

and may provide clients an advance supply of emergency

contraceptive pills on-site or by prescription, if requested.

Side effects (e.g., irregular vaginal bleeding) are a primary

reason for method discontinuation (54), so providers

should discuss ways the client might deal with potential side

effects to increase satisfaction with the method and improve

continuation (42).

• Develop a plan for follow-up. Providers should discuss an

appropriate follow-up plan with the client to meet their

individual needs, considering the client’s risk for

discontinuation. Follow-up provides an opportunity to

inquire about any initial difficulties the client might be

experiencing, and might reinforce the perceived accessibility

of the provider and increase rapport. Alternative modes

of follow-up other than visits to the service site, such as

telephone, e-mail, or text messaging, should be considered

(assuming confidentiality can be assured), as needed.

As noted previously, if a client chooses a method that

is not available on-site or during the visit, the provider

TABLE 1. Assessments to conduct when a female client is initiating a new method of reversible contraception

Cu-IUD and

LNG-IUD Implant Injectable

Combined

hormonal

contraception

Progestin-

only pills Condom

Diaphragm or

cervical

cap Spermicide

Examination

Blood pressure C C C A* C C C C

Weight (BMI) (weight [kg]/height [m]

) —

†

—

†

—

†

—

†

—

†

C C C

Clinical breast examination C C C C C C C C

Bimanual examination and cervical

inspection

A C C C C C A

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.

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MMWR / April 25, 2014 / Vol. 63 / No. 4 13

should schedule a follow-up visit with the client or provide

a referral for her or him to receive the method. The client

should be provided another method to use until she or he

can start the chosen method.

• Confirm the client’s understanding. Providers should assess

whether the client understands the information that was

presented. The client’s understanding of the most

important information about her or his chosen

contraceptive method should be documented in the

medical record (e.g., by a checkbox or written statement).

The teach-back method may be used to confirm the client’s

understanding by asking the client to repeat back messages

about risks and benefits and appropriate method use and

follow-up. If providers assess the client’s understanding, then

the check box or written statement can be used in place of a

written method-specific informed consent form. Topics that

providers may consider having the client repeat back include

the following: typical method effectiveness; how to use the

method correctly; protection from STDs; warning signs

for rare, but serious, adverse events and what to do if they

experience a warning sign; and when to return for follow-up.

Provide Counseling for Returning Clients

When serving contraceptive clients who return for ongoing

care related to contraception, providers should ask if the

client has any concerns with the method and assess its use.

The provider should assess any changes in the client’s medical

history, including changes in risk factors and medications that

might affect safe use of the contraceptive method. If the client

is using the method correctly and consistently and there are no

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

correct or consistent use of the method, the provider should

ask if the client would be interested in considering a different

method of contraception. If the client is interested, the steps

described above should be followed.

Counseling Adolescent Clients

Providers should give comprehensive information to

adolescent clients about how to prevent pregnancy (55–57).

This information should clarify that avoiding sex (i.e.,

abstinence) is an effective way to prevent pregnancy and STDs.

If the adolescent indicates that she or he will be sexually active,

providers should give information about contraception and

help her or him to choose a method that best meets her or his

individual needs, including the use of condoms to reduce the

risk of STDs. Long-acting reversible contraception is a safe

and effective option for many adolescents, including those

who have not been pregnant or given birth (35).

Providers of family planning services should offer confidential

services to adolescents and observe all relevant state laws and

any legal obligations, such as notification or reporting of child

abuse, child molestation, sexual abuse, rape, or incest, as well

as human trafficking (58,59). Confidentiality is critical for

adolescents and can greatly influence their willingness to access

and use services (60–67). As a result, multiple professional

medical associations have emphasized the importance of

providing confidential services to adolescents (68–70).

Providers should encourage and promote communication

between the adolescent and his or her parent(s) or guardian(s)

about sexual and reproductive health (71–86). Adolescents

who come to the service site alone should be encouraged to

talk to their parents or guardians. Educational materials and

programs can be provided to parents or guardians that help

them talk about sex and share their values with their child

(72,87). When both parent or guardian and child have agreed,

joint discussions can address family values and expectations

about dating, relationships, and sexual behavior.

In a given year, approximately 20% of adolescent births

represent repeat births (88), so in addition to providing

postpartum contraception, providers should refer pregnant

and parenting adolescents to home visiting and other programs

that have been demonstrated to provide needed support and

reduce rates of repeat teen pregnancy (89–94).

Services for adolescents should be provided in a “youth-

friendly” manner, which means that they are accessible,

equitable, acceptable, appropriate, comprehensive, effective,

and efficient for youth as recommended by the World Health

Organization (34).

Pregnancy Testing and Counseling

Providers of family planning services should offer pregnancy

testing and counseling services as part of core family planning

services, in accordance with recommendations of major

professional medical organizations, such as the American

College of Obstetricians and Gynecologists (ACOG) and the

American Academy of Pediatrics (AAP) (95–97).

Pregnancy testing is a common reason for a client to visit a

provider of family planning services. Approximately 65% of

pregnancies result in live births, 18% in induced abortion,

and 17% spontaneous fetal loss (98). Among live births, only

1% of infants are placed for adoption within their first month

of life (99).

The visit should include a discussion about her reproductive

life plan and a medical history that includes asking about

any coexisting conditions (e.g., chronic medical illnesses,

physical disability, psychiatric illness) (95,96). In most cases,

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

a qualitative urine pregnancy test will be sufficient; however,

in certain cases, the provider may consider performing a

quantitative serum pregnancy test, if exact hCG levels would

be helpful for diagnosis and management. The test results

should be presented to the client, followed by a discussion of

options and appropriate referrals.

Options counseling should be provided in accordance with

recommendations from professional medical associations, such as

ACOG and AAP (95–97). A female client might wish to include

her partner in the discussion; however, if a client chooses not to

involve her partner, confidentiality must be assured.

Positive Pregnancy Test

If the pregnancy test is positive, the clinical visit should include

an estimation of gestational age so that appropriate counseling

can be provided. If a woman is uncertain about the date of her

last normal menstrual period, a pelvic examination might be

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

to a provider for further evaluation. If ectopic pregnancy or

other pregnancy abnormalities or problems are suspected, the

provider should either manage the condition or refer the client

for immediate diagnosis and management.

Referral to appropriate providers of follow-up care should

be made at the request of the client, as needed. Every effort

should be made to expedite and follow through on all referrals.

For example, providers might provide a resource listing or

directory of providers to help the client identify options for

care. Depending upon a client’s needs, the provider may make

an appointment for the client, or call the referral site to let them

know the client was referred. Providers also should assess the

client’s social support and refer her to appropriate counseling

or other supportive services, as needed.

For clients who are considering or choose to continue the

pregnancy, initial prenatal counseling should be provided

in accordance with the recommendations of professional

medical associations, such as ACOG (97). The client should

be informed that some medications might be contraindicated

in pregnancy, and any current medications taken during

pregnancy need to be reviewed by a prenatal care provider

(e.g., an obstetrician or midwife). In addition, the client should

be encouraged to take a daily prenatal vitamin that includes

folic acid; to avoid smoking, alcohol, and other drugs; and

not to eat fish that might have high levels of mercury (97). If

there might be delays in obtaining prenantal care, the client

should be provided or referred for any needed STD screening

(including HIV) and vaccinations (36).

Negative Pregnancy Test

Women who are not pregnant and who do not want to

become pregnant at this time should be offered contraceptive

services, as described previously. The contraceptive counseling

session should explore why the client thought that she was

pregnant and sought pregnancy testing services, and whether

she has difficulties using her current method of contraception.

A negative pregnancy test also provides an opportunity to discuss

the value of making a reproductive life plan. Ideally, these services

will be offered in the same visit as the pregnancy test because

clients might not return at a later time for contraceptive services.

Women who are not pregnant and who are trying to become

pregnant should be offered services to help achieve pregnancy or

basic infertility services, as appropriate (see “Clients Who Want

to Become Pregnant” and “Basic Infertility Services”). They also

should be offered preconception health and STD services (see

“Preconception Health Services” and “STD services”).

Clients Who Want to

Become Pregnant

Providers should advise clients who wish to become pregnant

in accordance with the recommendations of professional

medical organizations, such as the American Society for

Reproductive Medicine (ASRM) (100).

Providers should ask the client (or couple) how long she or

they have been trying to get pregnant and when she or they

hope to become pregnant. If the client’s situation does not

meet one of the standard definitions of infertility (see “Basic

Infertility Services”), then she or he may be counseled about

how to maximize fertility. Key points are as follows:

• The client should be educated about peak days and signs

of fertility, including the 6-day interval ending on the day

of ovulation that is characterized by slippery, stretchy

cervical mucus and other possible signs of ovulation.

• Women with regular menstrual cycles should be advised

that vaginal intercourse every 1–2 days beginning soon

after the menstrual period ends can increase the likelihood

of becoming pregnant.

• Methods or devices designed to determine or predict the time

of ovulation (e.g., over-the-counter ovulation kits, digital

telephone applications, or cycle beads) should be discussed.

• It should be noted that fertility rates are lower among

women who are very thin or obese, and those who consume

high levels of caffeine (e.g., more than five cups per day).

• Smoking, consuming alcohol, using recreational drugs,

and using most commercially available vaginal lubricants

should be discouraged as these might reduce fertility.

Recommendations and Reports

MMWR / April 25, 2014 / Vol. 63 / No. 4 15

Basic Infertility Services

Providers should offer basic infertility care as part of

core family planning services in accordance with the

recommendations of professional medical organizations, such

as ACOG, ASRM, and the American Urological Association

(AUA) (96,101,102).

Infertility commonly is defined as the failure of a couple

to achieve pregnancy after 12 months or longer of regular

unprotected intercourse (101). Earlier assessment (such as

6 months of regular unprotected intercourse) is justified

for women aged >35 years, those with a history of oligo-

amenorrhea (infrequent menstruation), those with known or

suspected uterine or tubal disease or endometriosis, or those

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

if risk factors of male infertility are known to be present or

if there are questions regarding the male partner’s fertility

potential (102). Infertility visits to a family planning provider

are focused on determining potential causes of the inability to

achieve pregnancy and making any needed referrals to specialist

care (101,102). ASRM recommends that evaluation of both

partners should begin at the same time (101).

Basic Infertility Care for Women

The clinical visit should focus on understanding the client’s

reproductive life plan (24) and her difficulty in achieving

pregnancy through a medical history, sexual health assessment

and physical exam, in accordance with recommendations

developed by professional medical associations such as

ASRM (101) and ACOG (96). The medical history should

include past surgery, including indications and outcome(s),

previous hospitalizations, serious illnesses or injuries, medical

conditions associated with reproductive failure (e.g., thyroid

disorders, hirsutism, or other endocrine disorders), and

childhood disorders; results of cervical cancer screening and

any follow-up treatment; current medication use and allergies;

and family history of reproductive failure. In addition, a

reproductive history should include how long the client has

been trying to achieve pregnancy; coital frequency and timing,

level of fertility awareness, and results of any previous evaluation

and treatment; gravidity, parity, pregnancy outcome(s), and

associated complications; age at menarche, cycle length and

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

emphasize symptoms of thyroid disease, pelvic or abdominal

pain, dyspareunia, galactorrhea, and hirsutism (101).

The physical examination should include: height, weight, and

body mass index (BMI) calculation; thyroid examination to

identify any enlargement, nodule, or tenderness; clinical breast

examination; and assessment for any signs of androgen excess.

A pelvic examination should assess for: pelvic or abdominal

tenderness, organ enlargement or mass; vaginal or cervical

abnormality, secretions, or discharge; uterine size, shape, position,

and mobility; adnexal mass or tenderness; and cul-de-sac mass,

tenderness, or nodularity. If needed, clients should be referred

for further diagnosis and treatment (e.g., serum progesterone

levels, follicle-stimulating hormone/luteinizing hormone levels,

thyroid function tests, prolactin levels, endometrial biopsy,

transvaginal ultrasound, hysterosalpingography, laparoscopy,

and clomiphene citrate).

Basic Infertility Care for Men

Infertility services should be provided for the male partner

of an infertile couple in accordance with recommendations

developed by professional medical associations such as AUA

(102). Providers should discuss the client’s reproductive life

plan, take a medical history, and conduct a sexual health

assessment. AUA recommends that the medical history include

a reproductive history (102). The medical history should

include systemic medical illnesses (e.g., diabetes mellitus),

prior surgeries and past infections; medications (prescription

and nonprescription) and allergies; and lifestyle exposures. The

reproductive history should include methods of contraception,

coital frequency and timing; duration of infertility and prior

fertility; sexual history; and gonadal toxin exposure, including

heat. Patients also should be asked about their female partners’

history of pelvic inflammatory disease, their partners’ histories

of STDs, and problems with sexual dysfunction.

In addition, a physical examination should be conducted with

particular focus given to 1) examination of the penis, including

the location of the urethral meatus; 2) palpation of the testes

and measurement of their size; 3) presence and consistency of

both the vas deferens and epididymis; 4) presence of a varicocele;

5) secondary sex characteristics; and 6) a digital rectal exam

(102). Male clients concerned about their fertility should have

a semen analysis. If this test is abnormal, they should be referred

for further diagnosis (i.e., second semen analysis, endocrine

evaluation, post-ejaculate urinalysis, or others deemed necessary)

and treatment. The semen analysis is the first and most simple

screen for male fertility.

Infertility Counseling

Counseling provided during the clinical visit should be

guided by information elicited from the client during the

medical and reproductive history and the findings of the

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

physical exam. If there is no apparent cause of infertility

and the client does not meet the definition above, providers

should educate the client about how to maximize fertility (see

“Clients Who Want to Become Pregnant”). ACOG notes

the importance of addressing the emotional and educational

needs of clients with infertility and recommends that providers

consider referring clients for psychological support, infertility

support groups, or family counseling (96).

Preconception Health Services

Providers of family planning services should offer

preconception health services to female and male clients

in accordance with CDC’s recommendations to improve

preconception health and health care (24).

Preconception health services are beneficial because of

their effect on pregnancy and birth outcomes and their

role in improving the health of women and men. The term

preconception describes any time that a woman of reproductive

potential is not pregnant but at risk of becoming pregnant,

or when a man is at risk for impregnating his female partner.

Preconception health-care services for women aim to identify

and modify biomedical, behavioral, and social risks to a

woman’s health or pregnancy outcomes through prevention and

management. It promotes the health of women of reproductive

age before conception, and thereby helps to reduce pregnancy-

related adverse outcomes, such as low birthweight, premature

birth, and infant mortality (24). Moreover, the preconception

health services recommended here are equally important

because they contribute to the improvement of women’s health

and well-being, regardless of her childbearing intentions. CDC

recommends that preconception health services be integrated

into primary care visits made by women of reproductive age,

such as family planning visits (24).

In the family planning setting, providers may prioritize

screening and counseling about preconception health for

couples that are trying to achieve pregnancy and couples

seeking basic infertility services. Women who are using

contraception to prevent or delay pregnancy might also

benefit from preconception health services, especially those

at high risk of unintended pregnancy. A woman is at high

risk of unintended pregnancy if she is using no method or a

less effective method of contraception (e.g., barrier methods,

rhythm, or withdrawal), or has a history of contraceptive

discontinuation or incorrect use (38,39). A woman is at lower

risk of unintended pregnancy if she is using a highly effective

method, such as an IUD or implant, or has an established

history of using methods of contraception, such as injections,

pills, patch, or ring correctly and consistently (38,39). Clients

who do not want to become pregnant should also be provided

preconception health services, since they are recommended by

USPSTF for the purpose of improving the health of adults.

Recommendations for improving the preconception health

of men also have been identified, although the evidence base

for many of the recommendations for men is less than that

for women (103). This report includes preconception health

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

health of women (e.g., through reduced STD/HIV transmission).

Moreover, these services are important for improving the health

of men regardless of their pregnancy intention.

In a family planning setting, all women planning or capable

of pregnancy should be counseled about the need to take a daily

supplement containing 0.4 to 0.8 mg of folic acid, in accordance

with the USPSTF recommendation (Grade A) (104).

Other preconception health services for women and men

should include discussion of a reproductive life plan and

sexual health assessment (Boxes 2 and 4), as well as the

screening services described below (24,103,105). Services

should be provided in accordance with the cited clinical

recommendations, and any needed follow up (further

diagnosis, treatment) should be provided either on-site or

through referral.

Medical History

For female clients, the medical history should include

the reproductive history, history of poor birth outcomes

(i.e., preterm, cesarean delivery, miscarriage, and stillbirth),

environmental exposures, hazards and toxins (e.g., smoking,

alcohol, other drugs), medications that are known teratogens,

genetic conditions, and family history (24,105).

For male clients, the medical history should include asking about

the client’s past medical and surgical history that might impair his

reproductive health (e.g., genetic conditions, history of reproductive

failures, or conditions that can reduce sperm quality, such as obesity,

diabetes mellitus, and varicocele) and environmental exposures,

hazards and toxins (e.g., smoking) (103).

Intimate Partner Violence

Providers should screen women of childbearing age for

intimate partner violence and provide or refer women who screen

positive to intervention services, in accordance with USPSTF

(Grade B) recommendations (106).

Alcohol and Other Drug Use

For female and male adult clients, providers should screen for

alcohol use in accordance with the USPSTF recommendation

(Grade B) for how to do so, and provide behavioral counseling

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MMWR / April 25, 2014 / Vol. 63 / No. 4 17

interventions, as indicated (107). Screening adults for other

drug use and screening adolescents for alcohol and other drug

use has the potential to reduce misuse of alcohol and other

drugs, and can be recommended (105,108,109). However,

the USPSTF recommendation for screening for other drugs

in adults, and for alcohol and other drugs in adolescents, is an

“I,” and patients should be informed that there is insufficient

evidence to assess the balance of benefits and harms of this

screening (107,110).

Tobacco Use

For female and male clients, providers should screen for

tobacco use in accordance with the USPSTF recommendation

(111,112) for how to do so. Adults (Grade A) who use tobacco

products should be provided or referred for tobacco cessation

interventions, including brief behavioral counseling sessions

(<10 minutes) and pharmacotherapy delivered in primary

care settings (111). Adolescents (Grade B) should be provided

intervention to prevent initiation of tobacco use (112).

Immunizations

For female and male clients, providers should screen for

immunization status in accordance with recommendations

of CDC’s Advisory Committee on Immunization Practices

(113) and offer vaccination, as indicated, or provide referrals

to community providers for immunization. Female and male

clients should be screened for age-appropriate vaccinations,

such as influenza and tetanus–diphtheria–pertussis (Tdap),

measles, mumps, and rubella (MMR), varicella, pneumococcal,

and meningococcal. In addition, ACOG recommends that

rubella titer be performed in women who are uncertain about

MMR immunization (108). (For vaccines for reproductive

health-related conditions, i.e., human papillomavirus and

hepatitis B, see “Sexually Transmitted Disease Services.”)

Depression

For all clients, providers should screen for depression

when staff-assisted depression care supports are in place to

ensure accurate diagnosis, effective treatment, and follow-up

(114,115). Staff-assisted care supports are defined as clinical

staff members who assist the primary care clinician by

providing some direct depression care, such as care support or

coordination, case management, or mental health treatment.

The lowest effective staff supports consist of a screening nurse

who advises primary care clinicians of a positive screen and

provides a protocol facilitating referral to behavioral therapy.

Providers also may follow American Psychiatric Association

(116) and American Academy of Child and Adolescent

Psychiatry (117) recommendations to assess risk for suicide

among persons experiencing depression and other risk factors.

Height, Weight, and Body Mass Index

For all clients, providers should screen adult (Grade B) and

adolescent (Grade B) clients for obesity in accordance with

the USPSTF recommendation, and obese adults should be

referred for intensive counseling and behavioral interventions

to promote sustained weight loss (118,119). Clients likely will

need to be referred for this service. These interventions typically

comprise 12 to 26 sessions in a year and include multiple

behavioral management activities, such as group sessions,

individual sessions, setting weight-loss goals, improving diet

or nutrition, physical activity sessions, addressing barriers to

change, active use of self-monitoring, and strategizing how to

maintain lifestyle changes.

Blood Pressure

For female and male clients, providers should screen for

hypertension in accordance with the USPSTF’s recommendation

(Grade A) that blood pressure be measured routinely

among adults (120) and the Joint National Committee on

Prevention, Detection, Evaluation, and Treatment of High

Blood Pressure’s recommendation that persons with blood

pressure less than 120/80 be screened every 2 years, and every

year if prehypertensive (i.e., blood pressure 120–139/80–89)

(121). Providers also may follow AAP’s recommendation that

adolescents receive annual blood pressure screening (109).

Diabetes

For female and male clients, providers should follow the

USPSTF recommendation (Grade B) to screen for type 2

diabetes in asymptomatic adults with sustained blood pressure

(either treated or untreated) >135/80 mmHg (122).

Sexually Transmitted

Disease Services

Providers should offer STD services in accordance with CDC’s

STD treatment and HIV testing guidelines (36,123,124). It

is important to test for chlamydia annually

among young

sexually active females and for gonorrhea routinely among all

sexually active females at risk for infection because they can

cause tubal infertility in women if left untreated. Testing for

syphilis, HIV/AIDS, and hepatitis C should be conducted

as recommended (36,123,124). Vaccination for human

papillomavirus (HPV) and hepatitis B are also important parts

of STD services and preconception care (113).

STD services should be provided for persons with no signs or

symptoms suggestive of an STD. STD diagnostic management

recommendations are not included in these guidelines, so

providers should refer to CDC’s STD treatment guidelines

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

(36) when caring for clients with STD symptoms. STD services

include the following steps, which should be provided at the

initial visit and at least annually thereafter:

Step 1. Assess: The provider should discuss the client’s

reproductive life plan, conduct a standard medical history

and sexual health assessment (see text box above), and check

immunization status. A pelvic exam is not indicated in patients

with no symptoms suggestive of an STD.

Step 2. Screen: A client who is at risk of an STD

(i.e., sexually active and not involved in a mutually

monogamous relationship with an uninfected partner) should

be screened for HIV and the other STDs listed below, in

accordance with CDC’s STD treatment guidelines (36) and

recommendations for HIV testing of adults, adolescents,

and pregnant women in health-care settings (123). Clients

also should follow CDC’s recommendations for testing

for hepatitis C (124), and the Advisory Committee on

Immunization Practice’s recommendations on reproductive

health-related immunizations (113). It is important to follow

these guidelines both to ensure that clients receive needed

services and to avoid unnecessary screening.

Chlamydia

For female clients, providers should screen all sexually active

women aged ≤25 years for chlamydia annually, in addition

to sexually active women aged >25 years with risk factors for

chlamydia infection (36). Women aged >25 years at higher

risk include sexually active women who have a new or more

than one sex partner or who have a partner who has other

concurrent partners. Females with chlamydia infection should

be rescreened for re-infection at 3 months after treatment.

Pregnant women should be screened for chlamydia at the time

of their pregnancy test if there might be delays in obtaining

prenatal care (36).

For male clients, chlamydia screening can be considered for

males seen at sites with a high prevalence of chlamydia, such

as adolescent clinics, correctional facilities, and STD clinics

(36,125,126). Providers should screen men who have sex with

men (MSM) for chlamydia at anatomic sites of exposure, in

accordance with CDC’s STD treatment guidelines (36). Males

with symptoms suggestive of chlamydia (urethral discharge or

dysuria or whose partner has chlamydia) should be tested and

empirically treated at the initial visit. Males with chlamydia

infection should be re-screened for reinfection at 3 months (36).

Gonorrhea

For female clients, providers should screen clients for gonorrhea,

in accordance with CDC’s STD treatment guidelines (36).

Routine screening for N. gonorrhoeae in all sexually active women

at risk for infection is recommended annually (36). Women aged

<25 years are at highest risk for gonorrhea infection. Other risk

factors that place women at increased risk include a previous

gonorrhea infection, the presence of other STDs, new or multiple

sex partners, inconsistent condom use, commercial sex work, and

drug use. Females with gonnorrhea infection should be re-screened

for re-infection at 3 months after treatment. Pregnant women

should be screened for gonorrhea at the time of their pregnancy

test if there might be delays in obtaining prenatal care (36).

For male clients, providers should screen MSM for gonorrhea

at anatomic sites of exposure, in accordance with CDC’s STD

treatment guidelines (36). Males with symptoms suggestive of

gonorrhea (urethral discharge or dysuria or whose partner has

gonorrhea) should be tested and empirically treated at the initial

visit. Males with gonorrhea infection should be re-screened for

reinfection at 3 months after treatment (36,126–128).

Syphilis

For female and male clients, providers should screen clients for

syphilis, in accordance with CDC’s STD treatment guidelines

(36). CDC recommends that persons at risk for syphilis infection

should be screened. Populations at risk include MSM, commercial

sex workers, persons who exchange sex for drugs, those in adult

correctional facilities and those living in communities with high

prevalence of syphilis (36). Pregnant women should be screened

for syphilis at the time of their pregnancy test if there might be

delays in obtaining prenatal care (36).

HIV/AIDS

For female and male clients, providers should screen

clients for HIV/AIDS, in accordance with CDC HIV

testing guidelines (123). Providers should follow CDC

recommendations that all clients aged 13–64 years be screened

routinely for HIV infection and that all persons likely to be at

high risk for HIV be rescreened at least annually (123). Persons

likely to be at high risk include injection-drug users and their

sex partners, persons who exchange sex for money or drugs, sex

partners of HIV-infected persons, and MSM or heterosexual

persons who themselves or whose sex partners have had more

than one sex partner since their most recent HIV test. CDC

further recommends that screening be provided after the

patient is notified that testing will be performed as part of

general medical consent unless the patient declines (opt-out

screening) or otherwise prohibited by state law. The USPSTF

also recommends screening for HIV (Grade A) (129).

Hepatitis C

For female and male clients, CDC recommends one-time

testing for hepatitis C (HCV) without prior ascertainment of

HCV risk for persons born during 1945–1965, a population

with a disproportionately high prevalence of HCV infection

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MMWR / April 25, 2014 / Vol. 63 / No. 4 19

and related disease. Persons identified as having HCV

infection should receive a brief screening for alcohol use and

intervention as clinically indicated, followed by referral to

appropriate care for HCV infection and related conditions.

These recommendations do not replace previous guidelines for

HCV testing that are based on known risk factors and clinical

indications. Rather, they define an additional target population

for testing: persons born during 1945–1965 (124). USPSTF

also recommends screening persons at high risk for infection

for hepatitis C and one-time screening for HCV infection

for persons in the 1945–1965 birth cohort (Grade B) (130).

Immunizations Related to Reproductive Health

Female clients aged 11–26 years should be offered either

human papillomavirus (HPV) 2 or HPV4 vaccine for the

prevention of HPV and cervical cancer if not previously

vaccinated, although the series can be started in persons as

young as age 9 years (113); recommendations include starting

at age 11–12 years and catch up vaccine among females aged

13–26 who have not been vaccinated previously or have

not completed the 3-dose series through age 26. Routine

hepatitis B vaccination should be offered to all unvaccinated

children and adolescents aged <19 years and all adults who

are unvaccinated and do not have any documented history of

hepatitis B infection (113).

Male clients aged 11–21 years (minimum age: 9 years)

should be offered HPV4 vaccine, if not vaccinated previously;

recommendations include starting at age 11–12 years and catch

up vaccine among males aged 13–21 years who have not been

vaccinated previously or have not completed the 3-dose series

through age 21 years; vaccination is recommended among

at-risk males, including MSM and immune-compromised

males through age 26 years if not vaccinated previously or

males who have not completed the 3-dose series through age 26

years. Heterosexual males aged 22–26 years may be vaccinated

(131). Routine hepatitis B vaccination should be offered to all

unvaccinated children and adolescents aged <19 years, and all

unvaccinated adults who do not have a documented history

of hepatitis B infection (113).

Step 3. Treat: A client with an STD and her or his

partner(s) should be treated in a timely fashion to prevent

complications, re-infection and further spread of the infection

in the community in accordance with CDC’s STD treatment

guidelines; clients with HIV infection should be linked to

HIV care and treatment (36,123). Clients should be counseled

about the need for partner evaluation and treatment to avoid

reinfection at the time the client receives the positive test

results. For partners of clients with chlamydia or gonorrhea,

one option is to schedule them to come in with the client;

another option for partners who cannot come in with the client

is expedited partner therapy (EPT), as permissible by state laws,

in which medication or a prescription is provided to the patient

to give to the partner to ensure treatment. EPT is a partner

treatment strategy for partners who are unable to access care

and treatment in a timely fashion. Because of concerns related

to resistant gonorrhea, efforts to bring in for treatment partners

of patients with gonorrhea infection are recommended; EPT

for gonorrhea should be reserved for situations in which efforts

to treat partners in a clinical setting are unsuccessful and EPT

is a gonorrhea treatment of last resort.

All clients treated for chlamydia or gonorrhea should be

rescreened 3 months after treatment; HIV-infected females

with Trichomonas vaginalis should be linked to HIV care and

rescreened for T. vaginalis at 3 months. If needed, the client also

should be vaccinated for hepatitis B and HPV (113). Ideally,

STD treatment should be directly observed in the facility

rather than a prescription given or called in to a pharmacy.

If a referral is made to a service site that has the necessary

medication available on-site, such as the recommended

injectable antimicrobials for gonorrhea and syphilis, then the

referring provider must document that treatment was given.

Step 4. Provide risk counseling: If the client is at risk for

or has an STD, high-intensity behavioral counseling for sexual

behavioral risk reduction should be provided in accordance

with the USPSTF recommendation (Grade B) (132). One

high-intensity behavioral counseling model that is similar to

the contraceptive counseling model is Project Respect (133),

which could be implemented in family planning settings. All

sexually active adolescents are at risk, and adults are at increased

risk if they have current STDs, had an STD in the past

year, have multiple sexual partners, are in nonmonogamous

relationships, or are sexually active and live in a community

with a high rate of STDs.

Other key messages to give infected clients before they

leave the service site include the following: a) refrain from

unprotected sexual intercourse during the period of STD

treatment, 2) encourage partner(s) to be screened or to get

treatment as quickly as possible in accordance with CDC’s

STD treatment guidelines (partners in the past 60 days for

chlamydia and gonorrhea, 3 to 6 months plus the duration of

lesions or signs for primary and secondary syphilis, respectively)

if the partner did not accompany the client to the service site

for treatment, and 3) return for retesting in 3 months. If the

partner is unlikely to access treatment quickly, then EPT for

chlamydia or gonorrhea should be considered, if permissible

by state law.

A client using or considering contraceptive methods other

than condoms should be advised that these methods do not

protect against STDs. Providers should encourage a client

who is not in a mutually monogamous relationship with an

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

uninfected partner to use condoms. Patients who do not know

their partners’ infection status should be encouraged to get

tested and use condoms or avoid sexual intercourse until their

infection status is known.

Related Preventive Health Services

For many women and men of reproductive age, a family

planning service site is their only source of health care;

therefore, visits should include provision of or referral to other

preventive health services. Providers of family planning services

that do not have the capacity to offer comprehensive primary

care services should have strong links to other community

providers to ensure that clients have access to primary care. If

a client does not have another source of primary care, priority

should be given to providing related reproductive health

services or providing referrals, as needed.

For clients without a primary care provider, the following

screening services should be provided, with appropriate

follow-up, if needed, while linking the client to a primary care

provider. These services should be provided in accordance with

federal and professional medical recommendations cited below

regarding the frequency of screening, the characteristics of the

clients that should be screened, and the screening procedures

to be used.

Medical History

USPSTF recommends that women be asked about family

history that would be suggestive of an increased risk for

deleterious mutations in BRCA1 or BRCA2 genes (e.g.,

receiving a breast cancer diagnosis at an early age, bilateral

breast cancer, history of both breast and ovarian cancer,

presence of breast cancer in one or more female family

members, multiple cases of breast cancer in the family, both

breast and ovarian cancer in the family, one or more family

members with two primary cases of cancer, and Ashkenazi

background). Women with identified risk(s) should be referred

for genetic counseling and evaluation for BRCA testing

(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).

Cervical Cytology

Providers should provide cervical cancer screening to clients

receiving related preventive health services. Providers should

follow USPSTF recommendations to screen women aged

21–65 years with cervical cytology (Pap smear) every 3 years,

or for women aged 30–65 years, screening with a combination

of cytology and HPV testing every 5 years (Grade A) (136).

Cervical cytology no longer is recommended on an annual

basis. Further, it is not recommended (Grade D) for women

aged <21 years (136). Women with abnormal test results should

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

a contraceptive method (42).

Providers should also follow ACOG and AAP recommendations

that a genital exam should accompany a cervical cancer screening

to inspect for any suspicious lesions or other signs that might

indicate an undiagnosed STD (96,97,138).

Clinical Breast Examamination

Despite a lack of definitive data for or against, clinical

breast examination has the potential to detect palpable breast

cancer and can be recommended. ACOG recommends

annual examination for all women aged >19 years (108).

ACS recommends screening every 3 years for women aged

20–39 years, and annually for women aged ≥40 years (139).

However, the USPSTF recommendation for clinical breast

exam is an I, and patients should be informed that there is

insufficient evidence to assess the balance of benefits and harms

of the service (140).

Mammography

Providers should follow USPSTF recommendations

(Grade B) to screen women aged 50–74 years on a biennial

basis; they should screen women aged <50 years if other

conditions support providing the service to an individual

patient (140).

Genital Examination

For adolescent males, examination of the genitals should be

conducted. This includes documentation of normal growth and

development and other common genital findings, including

hydrocele, varicocele, and signs of STDs (141). Components

of this examination include inspecting skin and hair, palpating

inguinal nodes, scrotal contents and penis, and inspecting the

perinanal region (as indicated).

Summary of Recommendations for

Providing Family Planning and

Related Preventive Health Services

The screening components for each family planning and

related preventive health service are provided in summary

checklists for women (Table 2) and men (Table 3). When

considering how to provide the services listed in these

recommendations (e.g., the screening components for each

Recommendations and Reports

MMWR / April 25, 2014 / Vol. 63 / No. 4 21

service, risk groups that should be screened, the periodicity of

screening, what follow-up steps should be taken if screening

reveals the presence of a health condition), providers should

follow CDC and USPSTF recommendations cited above,

or, in the absence of CDC and USPSTF recommendations,

the recommendations of professional medical associations.

Following these recommendations is important both to ensure

clients receive needed care and to avoid unnecessary screening

of clients who do not need the services.

The summary tables describe multiple screening steps, which

refer to the following: 1) the process of asking questions about

a client’s history, including a determination of whether risk

factors for a disease or health condition exist; 2) performing

a physical exam; and 3) performing laboratory tests in

at-risk asymptomatic persons to help detect the presence of

a specific disease, infection, or condition. Many screening

recommendations apply only to certain subpopulations

(e.g., specific age groups, persons who engage in specific risk

behaviors or who have specific health conditions), or some

screening recommendations apply to a particular frequency

(e.g., a cervical cancer screening is generally recommended

every 3 years rather than annually). Providers should be aware

that the USPSTF also has recommended that certain screening

services not be provided because the harm outweighs the

benefit (see Appendix F).

When screening results indicate the potential or actual

presence of a health condition, the provider should either provide

or refer the client for the appropriate further diagnostic testing or

treatment in a manner that is consistent with the relevant federal

or professional medical associations’ clinical recommendations.

Conducting Quality Improvement

Service sites that offer family planning services should

have a system for conducting quality improvement, which is

designed to review and strengthen the quality of services on an

ongoing basis. Quality improvement is the use of a deliberate

and continuous effort to achieve measurable improvements

in the identified indicators of quality of care, which improve

the health of the community (142). By improving the quality

of care, family planning outcomes, such as reduced rates of

unintended pregnancy, improved patient experiences, and

reduced costs, are more likely to be achieved (10,12,143,144).

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

conducting quality improvement of family planning services:

1) determine which measures are needed to monitor quality;

2) collect the information needed; and 3) use the findings to

make changes to improve quality (147). Ideally, these steps

will be conducted on a frequent (optimally, quarterly) and

ongoing basis. However, since quality cuts across all aspects

of a program, not all domains of quality can necessarily be

considered at all times. Within a sustainable system of quality

improvement, programs can opt to focus on a subset of quality

dimensions and their respective measures.

Determining Which Measures Are Needed

Performance measures provide information about how

well the service site is meeting pre-established goals (148).

The following questions should be considered when selecting

performance measures (143):

• Is the topic important to measure and report? For example,

does it address a priority aspect of health care, and is there

opportunity for improvement?

• What is the level of evidence for the measure (e.g., that a

change in the measure is likely to represent a true change in

health outcomes)? Does the measure produce consistent

(reliable) and credible (valid) results about the quality of care?

• Are the results meaningful and understandable and useful

for informing quality improvement?

• Is the measure feasible? Can it be implemented without

undue burden (e.g., captured with electronic data or

electronic health records)?

Performance measures should consider the quality of the

structure of services (e.g., the characteristics of the settings in which

providers deliver health care, including material resources, human

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)

(149). They also may assess each dimension of quality services

(10,13). Examples of measures that can be used for monitoring the

quality of family planning services (150) and suggested measures

that might help providers monitor quality of care have been listed

(Table 6). However, other measures have been developed that also

might be useful (151–153). Service sites that offer family planning

services should select, measure, and assess at least one intermediate

or outcome measure on an ongoing basis, for which the service site

can be accountable. Structure- and process-based measures that

assess the eight dimensions of quality services may be used to better

determine how to improve quality (154).

Collecting Information

Once providers have determined what information is needed,

the next steps are to collect and use that information to improve

the quality of care. Commonly used methods of data collection

include the following:

Recommendations and Reports

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

TABLE 2. Checklist of family planning and related preventive health services for women

Screening components

Family planning services

(provide services in accordance with the appropriate clinical recommendation)

Related preventive

health services

Contraceptive

services*

Pregnancy testing and

counseling Basic infertility services

Preconception health

services STD 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

hormonal methods

for clients aged ≥35

years)

Screen

Immunizations

Screen Screen for HPV &

HBV

§§

Depression

§,¶

Screen

Folic acid

§,¶

Screen

Physical examamination

Height, weight and BMI

§,¶

Screen (hormonal

methods)

††

Screen Screen

Blood pressure

§,¶

Screen (combined

hormonal methods)

Screen

§§

Clinical breast exam** Screen Screen

§§

Pelvic exam

§,

** Screen (initiating

diaphragm or IUD)

Screen (if clinically

indicated)

Screen

Signs of androgen excess** Screen

Thyroid exam** Screen

Laboratory testing

Pregnancy test ** Screen (if clinically

indicated)

Screen

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

delivery activities can be reviewed, including encounters

and claims data, client medical records, facility logbooks,

and others. It is important that records be carefully

designed, sufficiently detailed, provide accurate

information, and have access restricted to protect

confidentiality. The use of electronic health records can

facilitate some types of medical record review.

• Exit interview with the client. A patient is asked (through

either a written or in-person survey) to describe what

happened during the encounter or their assessment of their

satisfaction with the visit. Both quantitative (close-ended

questions) and qualitative (open-ended questions)

methods can be used. Limitations include a bias toward

clients reporting higher degrees of satisfaction, and the

Recommendations and Reports

MMWR / April 25, 2014 / Vol. 63 / No. 4 23

TABLE 3. Checklist of family planning and related preventive health services for men

Screening components and source

of recommendation

Family planning services

(provide services in accordance with the appropriate clinical recommendation)

Related preventive

health servicesContraceptive services*

Basic infertility

services

Preconception

health services

†

STD 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

indicated)

Screen (if clinically

indicated)

Screen

§§

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

clients are being interviewed.

• Facility audit. Questions about a service site’s structure

(e.g., on-site availability of a broad range of FDA-approved

methods) and processes (e.g., skills and technical

competence of staff, referral mechanisms) can be used to

determine the readiness of the facility to serve clients.

• Direct observation. A provider’s behavior is observed

during an actual encounter with a client. Evaluation of a

full range of competencies, including communication

skills, can be carried out. A main limitation is that the

observer’s presence might influence the provider’s

performance.

• Interview with the health-care provider. Providers are

interviewed about how specific conditions are managed.

Both closed- and open-ended questions can be used,

although it is important to frame the question so that the

‘correct’ answer is not suggested. A limitation is that

providers tend to over-report their performance.

Consideration and Use of the Findings

After data are collected, they should be tabulated, analyzed,

and used to improve care. Staff whose performance was assessed

should be involved in the development of the data collection

tools and analysis of results. Analysis should address the

following questions (155):

• What is the performance level of the facility?

• Is there a consistent pattern of performance among

providers?

• What is the trend in performance?

• What are the causes of poor performance?

• How can performance gaps be minimized?

Given the findings, service site staff should use a systematic

approach to identifying ways to improve the quality of care.

One example of a systematic approach to improving the

quality of care is the “Plan, Do, Study, and Act” (PDSA) model

(147,156), in which staff first develop a plan for improving

quality, then execute the plan on a small scale, evaluate feedback

to confirm or adjust the plan, and finally, make the plan

Recommendations and Reports

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

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

Type of measure and dimension of quality Measure Source

Health outcome • Unintended pregnancy

• 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]

PIMS*

Safe (Structure) • Proportion of providers that follow the most current CDC recommendations on

contraceptive safety

Effective

(Structure, or the characteristics of the

settings in which providers deliver health

care, including material resources,

human resources, and organizational

structure)

• Site dispenses or provides on-site a full range of FDA-approved contraceptive methods

to meet the diverse reproductive needs and goals of clients; short-term hormonal,

long-acting reversible contraception (LARC), emergency contraception (EC).

• Proportion of female users aged ≥24 years who are screened annually for chlamydial

infection.

• 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.

PIMS*

Client-centered

(Process, or whether services are provided

correctly and completely, and how

clients perceive the care they receive)

• Proportion of clients who report the provider communicates well, shows respect,

spends enough time with the client, and is informed about the client’s medical

history.

• 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.

CAHPS

†

RQIP

Efficient

(Structure)

• Site uses electronic health information technology or electronic health records to

improve client reproductive health.

PIMS*

Timely

(Structure and process)

• Average number of days to the next appointment.

• 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.

PIMS*

Accessible

(Structure and process)

• Site offers family planning services during expanded hours of operation.

• Proportion of total family planning encounters that are encounters with ongoing or

continuing users.

• 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.

PIMS*

CAHPS–PCMH item set

on care coordination

†

Equitable

(Structure)

• Site offers language assistance at all points of contact for the most frequently

encountered language(s).

PIMS*

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

the quality of care include developing job aids, providing

task-specific training for providers, conducting more patient

education, or strengthening relationships with referral sites

through formal memoranda of understanding (146).

Conclusion

The United States continues to face substantial challenges to

improving the reproductive health of the U.S. population. The

recommendations in this report can contribute to improved

reproductive health by defining a core set of family planning

Recommendations and Reports

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

services for women and men, describing how to provide

contraceptive and other family planning services to both adult

and adolescent clients, and encouraging the use of the family

planning visit to provide selected preventive health services for

women and men. This guidance is intended to assist primary

care providers to offer the family planning services that will

help persons and couples achieve their desired number and

spacing of children and increase the likelihood that those

children are born healthy.

Recommendations are updated periodically. The most recent

versions are available at http://www.hhs.gov/opa.

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The recommendations were developed jointly under the

auspices of CDC’s Division of Reproductive Health (DRH)

and the Office of Population Affairs (OPA), in consultation

with a wide range of experts and key stakeholders. A

multistage process that drew on established procedures for

developing clinical guidelines (1,2) was used to develop the

recommendations. In April 2010, an Expert Work Group

(EWG) comprising family planning clinical providers, program

administrators, representatives from relevant federal agencies,

and representatives from professional medical organizations

was created to advise OPA and CDC on the structure and

content of the revised recommendations and to help make the

recommendations more feasible and relevant to the needs of

the field. This group made two key initial recommendations:

1) to examine the scientific evidence for three priority areas of

focus identified as key components of family planning service

delivery, (i.e., counseling and education, serving adolescents,

and quality improvement); and 2) to guide providers of family

planning services in the use of various recommendations for

how to provide clinical care to women and men.

Developing Recommendations on

Counseling, Adolescent Services,

and Quality Improvement

Systematic reviews of the published literature from January 1985

through December 2010 were conducted for each priority topic

to identify evidence-based and evidence-informed approaches to

family planning service delivery. Standard methods for conducting

the reviews were used, including the development of key questions

and analytic frameworks, the identification of the evidence base

through a search of the published as well as “gray literature”

(i.e., studies published somewhere other than in a peer-reviewed

journal), and a synthesis of the evidence in which findings were

summarized and the quality of individual studies was considered,

using the methodology of the U.S. Preventive Services Task Force

(USPSTF) (3). Eight databases were searched (i.e., MEDLINE,

PsychInfo, PubMed, CINAHL, Cochrane, EMBASE, POPLINE,

and the U.K. National Clearinghouse Service Economic

Evaluation Database) and were restricted to literature from the

United States and other developed countries. Summaries of the

evidence used to prepare these recommendations will appear in

background papers that will be published separately.

In May 2011, three technical panels (one for each priority

topic) comprising subject matter experts were convened

to consider the quality of the evidence and suggest what

recommendations might be justified on the basis of the

evidence. CDC and OPA used this feedback to develop core

recommendations for counseling, serving adolescents, and

quality improvement. EWG members subsequently reviewed

these core recommendations; EWG members differed from the

subject matter experts in that they were more familiar with the

family planning service delivery context and could comment

on the feasibility and appropriateness of the recommendations

as well as on their scientific justification. EWG members met

to consider the core recommendations using 1) the quality

of the evidence; 2) the positive and negative consequences of

implementing the recommendations on health outcomes, costs

or cost-savings, and implementation challenges; and 3) the

relative importance of these consequences (e.g., the ability of

the recommendations to have a substantial effect on health

outcomes may be weighed more than the logistical challenges

of implementing them) (1). In certain cases, when the evidence

was inconclusive or incomplete, recommendations were made on

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 Clinical Services

DRH and OPA staff members synthesized recommendations

for clinical care for women and for men that were developed

by >35 federal and professional medical organizations. They

were assisted in this effort by staff from OPA’s Office of Family

Planning Male Training Center and from CDC’s Division of

STD Prevention, Division of Violence Prevention, Division

of Immunization Services, and Division of Cancer Prevention

and Control. The synthesis was needed because clinical

recommendations are sometimes inconsistent with each other

and can vary by the extent to which they are evidence-based.

The clinical recommendations addressed contraceptive services,

achieving pregnancy, basic infertility services, preconception

health services, sexually transmitted disease services, and related

health-care services.

An attempt was made to apply the Institute of Medicine’s

criteria for clinical practice guidelines when deciding which

professional medical organizations to include in the review (2).

However, many organizations did not articulate the process

used to develop the recommendations fully, and many did not

Appendix A

How the Recommendations Were Developed

Recommendations and Reports

MMWR / April 25, 2014 / Vol. 63 / No. 4 31

conduct comprehensive and systematic reviews of the literature.

In the end, to be included in the synthesis, the recommending

organization had to be a federal agency or major professional

medical organization that represents established medical

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

for the United States.

In July 2011, two technical panels comprising subject matter

experts on clinical services for women and men were convened

to review the synthesis of federal and professional medical

recommendations, reconcile inconsistent recommendations,

and provide individual feedback to CDC and OPA about the

implications for family planning service delivery. CDC and OPA

used this individual feedback to develop core recommendations

for clinical services. The core recommendations were subsequently

reviewed by EWG members, and feedback was used to finalize

the core recommendations and write this report.

Members of the technical panels recommended that

contraceptive services, pregnancy testing and counseling,

services to achieve pregnancy, basic infertility care, STD services,

and other preconception health services should be considered

family planning services. This feedback considered federal

statute and regulation, CDC and USPSTF recommendations

for clinical care, and EWG members’ opinion.

Because CDC’s preconception health recommendations

include many services, the panel narrowed the range of

preconception services that were included by using the following

criteria: 1) the Select Panel on Preconception Care (4) had

assigned an A or B recommendation to that service for women,

which means that there was either good or fair evidence to

support the recommendation that the condition be considered

in a preconception care evaluation (Table 1), or 2) the service

was included among recommendations made by experts in

preconception health for males (5). Services for men that

addressed health conditions that affect reproductive capacity

or pregnancy outcomes directly were included as preconception

health; services that addressed men’s health but that were not

related directly to pregnancy outcomes were considered to be

related preventive health services.

The Expert Work Group noted that more preventive services

are recommended than can be offered feasibly in some settings.

However, a primary purpose of this report is to set a broad

framework within which individual clinics will tailor services

to meet the specific needs of the populations that they serve.

In addition, EWG members identified specific subgroups that

should have the greatest priority for preconception health

services (i.e., those trying to achieve pregnancy and those

at high risk of unintended pregnancy). Future operational

research should provide more information about how to deliver

these services most efficiently during multiple visits to clients

with diverse needs.

Determining How Clinical Services

Should Be Provided

Various federal agencies and professional medical associations

have made recommendations for how to provide family

planning services. When considering these recommendations,

the Expert Work Group used the following hierarchy:

• Highest priority was given to CDC guidelines because

they are developed after a rigorous review of scientific

evidence. CDC guidelines tailor recommendations for

higher risk individuals, (whereas USPSTF focuses on

average risk individuals), who are more representative of

the clients seeking family planning services.

• When no CDC guideline existed to guide the

recommendations, the relevant USPSTF A or B

recommendations (which indicate a high or moderate

certainty that the benefit is moderate to substantial) were

used. USPSTF recommendations are made on the basis of

a thorough review of the available evidence.

• If neither a CDC nor a USPSTF A or B recommendation

existed, the recommendations of selected major professional

medical associations were considered as resources. The

American Academy of Pediatrics’ (AAP) Bright Futures

guidelines (6) were used as the primary source of

recommendations for adolescents when no CDC or

USPSTF recommendations existed.

• For a limited number of recommendations, there were no

federal or major professional medical recommendations, but

the service was recommended by EWG members on the basis

of expert opinion for family planning clients.

In some cases, a service was graded as an I recommendation

by USPSTF for the general population (an I recommendation

means that the current evidence is insufficient to assess the balance

of benefits and harms of the service, so if the service is offered,

patients should be informed of this fact), but either CDC, EWG

members, or another organization recommended the service for

women or men seeking family planning services. The situations

in which this occurred and the reasons why the service was

recommended despite its receiving an I recommendation by

USPSTF have been summarized (Table 2). The approach used to

consider the evidence and make recommendations that are used

by USPSTF have been summarized (Tables 3 and 4) (7).

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

References

1. GRADE Working Group. GRADE: going from evidence to

recommendations. BMJ 2008;336:1049–51.

2. Institute of Medicine. Clinical practice guidelines we can trust. Washington,

DC: The National Academies Press; 2011. Available at http://www.nap.

edu/catalog.php?record_id=13058.

3. US Preventive Services Task Force. USPSTF: methods and processes.

Rockville, MD: US Department of Health and Human Services, Agency

for Healthcare Research and Quality; 2013. Available at http://www.

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.

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

preconception care: preconception care for men. Am J Obstet Gynecol

2008;199(Suppl 2):S389–95.

6. Committee on Practice and Ambulatory Medicine, Bright Futures

Periodicity Schedule Workgroup. 2014 recommendations for pediatric

preventive health care. Pediatrics 2014;133;568.

7. US Preventive Services Task Force. Grade definitions. Rockville, MD: US

Department of Health and Human Services, Agency for Healthcare Research

and Quality; 2013. Available at http://www.uspreventiveservicestaskforce.

org/uspstf/grades.htm.

Recommendations and Reports

MMWR / April 25, 2014 / Vol. 63 / No. 4 33

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.

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.

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

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

benefit is substantial.

This service should be offered or provided.

B USPSTF recommends the service. There is high certainty that the net

benefit is moderate, or there is moderate certainty that the net

benefit is moderate to substantial.

This service should be offered or provided.

C Clinicians may provide this service to selected patients depending on

individual circumstances. However, for a majority of persons without

signs or symptoms there is likely to be only a limited benefit from

this service.

This service should be offered or provided only if other

considerations support the offering or providing the service in an

individual patient.

D USPSTF recommends against the service. There is moderate or high

certainty that the service has no net benefit or that the harms

outweigh the benefits.

Use of this service should be discouraged.

I Statement USPSTF concludes that the current evidence is insufficient to assess

the balance of benefits and harms of the service. Evidence is lacking,

of poor quality, or conflicting, and the balance of benefits and harms

cannot be determined.

The clinical considerations section of USPSTF recommendation

statement should be consulted. If the service is offered, patients

should be educated about the uncertainty of the balance of

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.

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MMWR / April 25, 2014 / Vol. 63 / No. 4 35

Sixteen core recommendations that were considered by

the Expert Work Group (EWG) are presented below. Each

recommendation is accompanied by a summary of the

relevant evidence (full summaries of which will be published

separately), a list of potential consequences of implementing

the recommendation, and its rationale. When considering the

recommendations, the Expert Work Group was divided into

two groups (one comprising seven members and the other five

members), and each group considered separate recommendations.

Definition of Family

Planning Services

Recommendation: Primary care providers should offer the

following family planning services: contraceptive services for

women and men who want to prevent pregnancy and space

births, pregnancy testing and counseling, help for clients who

wish to achieve pregnancy, basic infertility services, sexually

transmitted disease (STD) services and preconception health

services to improve the health of women, men, and infants.

Quality of evidence: A systematic review was not conducted;

the recommendation was made on the basis of federal statute

and regulation (1,2), CDC clinical recommendations (3–5),

and expert opinion.

Potential consequences: Adding preconception health

services means that more women and men will receive

preconception health services. The recommended services

also will promote the health of women and men even if

they do not have children. The human and financial cost of

providing preconception health services might mean that fewer

contraceptive and other services can be offered in some settings.

Rationale: Services to prevent and achieve pregnancy

are core to the federal government’s efforts to promote

reproductive health. Adding preconception health as a family

planning service is consistent with this mission; it emphasizes

achieving a healthy pregnancy and also promotes adult health.

Adding preconception health is also consistent with CDC

recommendations to integrate preconception health services

into primary care platforms (3). All seven EWG members

agreed to this recommendation.

Preconception Health — Women

Recommendation: Preconception health services for

women include the following screening services: reproductive

Appendix B

The Evidence, Potential Consequences, and Rationales for Core Recommendations

life plan; medical history; sexual health assessment; intimate

partner violence, alcohol, and other drug use; tobacco use;

immunizations; depression; body mass index (BMI); blood

pressure; chlamydia, gonorrhea, syphilis, and HIV/AIDS; and

diabetes. All female clients also should be counseled about the

need to take a daily supplement of folic acid. When screening

results indicate the presence of a health condition, the provider

should take steps either to provide or to refer the client for

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’

recommendations to enable clients who need services to receive

them and to avoid over-screening.

Quality of evidence: A systematic review was not conducted;

the recommendation was made on the basis of CDC’s

recommendations to improve preconception health and health

care (3) and a review of preconception health services by an

expert panel on preconception care for women (6).

Potential consequences: More women will receive specified

preconception health services, which will improve the health of

infants and women. The evidence base for preconception health

is not fully established. There is a potential risk that a client with

a positive screen will not be able to afford treatment if the client is

uninsured and not eligible for public programs. The human and

financial cost of providing preconception health services might

mean that fewer contraceptive and other services can be offered.

Rationale: The potential benefits to the health of women and

infants were thought by the panel to be greater than the costs,

potential harms, and opportunity costs of providing these services.

Implementation (e.g., training and monitoring of providers) can

address the issues related to providers over-screening and not

following the federal and professional medical recommendations.

CDC will continue to monitor related research and modify these

recommendations, as needed. Health-care reform might make

follow-up care more available to low-income clients. All seven

EWG members agreed to this recommendation.

Preconception Health — Men

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;

BMI; blood pressure; chlamydia, gonorrhea, syphilis, and

HIV/AIDS; and diabetes. When screening results indicate

the presence of a health condition, the provider should take

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

steps either to provide or to refer the client for 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’ recommendations to

ensure that clients who need services receive them and to avoid

over-screening.

Quality of evidence: A systematic review was not conducted;

the recommendation was made on the basis of CDC’s

recommendations to improve preconception health and

health care (3) and a review of preconception health services

for men (7).

Potential consequences: More men will receive

preconception health services, which might improve infant and

men’s health. The evidence base for preconception health is not

well established and is less than that for women’s preconception

health. There is a risk of over-screening if recommendations

are not followed. There is a potential risk that a client with

a positive screen might not be able to afford treatment if the

client is uninsured and not eligible for public programs. The

human and financial cost of providing preconception health

services might mean that fewer contraceptive and other services

can be offered.

Rationale: The potential benefits to men and infant health

were thought by the panel to be greater than the costs, potential

harms, and opportunity costs of not providing these services.

Implementation (e.g., training and monitoring of providers)

can address the issues related to providers over-screening

and not following the federal and professional medical

recommendations. CDC will continue to monitor related

research and modify these recommendations, as needed.

Health-care reform might make follow-up care more available

to low-income clients. All seven EWG members agreed to this

recommendation.

Contraceptive Services —

Contraceptive Counseling Steps

Recommendation: To help a client who is initiating or

switching to a new method of contraception, providers should

follow these steps, which are in accordance with the key principles

for providing quality counseling: 1) establish and maintain

rapport with the client; 2) obtain clinical and social information

from the client; 3) work with the client interactively to select the

most effective and appropriate contraceptive method for her or

him; 4) provide a physical assessment related to contraceptive

use, when warranted; and 5) provide the contraceptive method

along with instructions about correct and consistent use, help

the client develop a plan for using the selected method and for

follow-up, and confirm understanding.

Quality of evidence: Twenty-two studies were identified

that examined the impact of contraceptive counseling

in clinical settings and met the inclusion criteria. Of the

16 studies that focused on adults or mixed populations

(adolescents and adults) (8–23), 11 found a statistically

significant positive impact of counseling interventions with low

(11,12,14–16,18–21), moderate (8), or unrated (22) intensity

on at least one outcome of interest; study designs included two

cross-sectional surveys (14,22), one pre-post study (21), one

prospective cohort study (8), one controlled trial (15), and

six randomized controlled trials (RCTs) (11,12,16,18–20).

Six studies examined the impact of contraceptive counseling

among adolescents (24–29), with four finding a statistically

significant positive impact of low-intensity (27) or moderate-

intensity (24,25,29) counseling interventions on at least one

outcome of interest; study designs included two pre-post

studies (24,30), one controlled trial (29), and one RCT (27). In

addition, five studies were identified that examined the impact

of reminder system interventions in clinical settings on family

planning outcomes and met the inclusion criteria (31–35); of

these, two found a statistically significant positive impact of

reminder systems on perfect oral contraceptive compliance, a

retrospective historical nonrandomized controlled trial that

examined daily reminder email messages (31) and a cohort

study that examined use of a small reminder device that

emitted a daily audible beep (34). In addition, two studies

examined the impact of reminder systems among depot

medroxyprogesterone acetate users (DMPA) (33,35) with one,

a retrospective cohort study, finding a statistically significant

positive impact of receiving a wallet-sized reminder card with

the date of the next DMPA injection and a reminder postcard

shortly before the next injection appointment on timely

DMPA injections. Statements about safety and unnecessary

medical examinations and tests are made on the basis of CDC

guidelines on contraceptive use (36,37).

Potential consequences: Fewer clients will use methods that

are not safe for them, there will be increased contraceptive use,

increased use of more effective methods, increased continuation

of method use, increased use of dual methods, increased

knowledge, increased satisfaction with services, and increased

use of repeat or follow-up services.

Rationale: Making sure that a contraceptive method is

safe for an individual client is a fundamental responsibility of

all providers of family planning services. Removing medical

barriers to contraceptive use is key to increasing access

to contraception and helping clients prevent unintended

pregnancy. Consistent use of contraceptives is needed to prevent

unintended pregnancies, so appropriate counseling is critical

to ensure clients make the best possible choice of methods for

their unique circumstances, and are supported in continued

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MMWR / April 25, 2014 / Vol. 63 / No. 4 37

use of the chosen method. The principles of quality counseling,

from which the steps listed in the recommendations are based,

are supported by a substantial body of evidence and expert

opinion. Future research to evaluate the five principles will be

monitored and the recommendations modified, as needed. All

seven EWG members agreed to this recommendation.

Contraceptive Services — Tiered

Approach to Counseling

Recommendation: For clients who might want to get

pregnant in the future and prefer reversible methods of

contraception, providers should use a tiered approach to

presenting a broad range of contraceptive methods (including

long-acting reversible contraception such as intrauterine

devices and contraceptive implants), in which the most

effective methods are presented before less effective methods.

Quality of evidence: National surveys have demonstrated

low rates of LARC use overall (38,39). However, Project

CHOICE has demonstrated high uptake of long-acting

reversible contraception (approximately two thirds of clients

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%

of teen mothers with a recent live birth are using long-acting

reversible contraception postpartum in Colorado, which

demonstrates high levels of acceptance in the context of a

statewide program to remove financial barriers (41).

Potential consequences: Use of long-acting reversible

contraception has the potential to help many more persons

prevent unintended pregnancy because of its ease of use, safety,

and effectiveness. Several questions were raised about ethical

issues in using a tiered approach to counseling. First, is it ethical

to educate about long-acting reversible contraception when

the methods are not all available on-site? Second, conversely,

is it ethical not to inform clients about the most effective

methods? In other health service areas, the standard of care

is to inform the client about the most effective treatment

(e.g., blood pressure medications), so the client can make a

fully informed decision, and this standard should apply in

this instance as well. On the basis of historic experiences,

there is a need to ensure that methods always are offered on

a completely voluntary and noncoercive basis. Health-care

reform might make contraceptive services more available to

the majority of clients.

Rationale: Providers have an obligation to inform clients

about the most effective methods available, even if they cannot

provide them. Further, health-care reform will reduce the

financial barriers to long-acting reversible contraception for

many persons. The potential increase in use of long-acting

reversible contraception and other more effective methods is

likely to help reduce rates of unintended pregnancy. All seven

EWG members agreed to this recommendation.

Contraceptive Services — Broad

Range of Methods

Recommendation: A broad range of methods should be

available on-site or through referral.

Quality of evidence: Three descriptive studies from the review

of quality improvement literature identified contraceptive choice

as an important aspect of quality care (42–44).

Potential consequences: Clients will be more likely to select

a method that they will use consistently and correctly.

Rationale: A central tenet of quality health care is that

it be client-centered. Being able to provide a client with

a method that best fits her or his unique circumstances is

essential for that reason. All seven EWG members agreed to

this recommendation.

Contraceptive Services — Education

Recommendation: The content, format, method, and

medium for delivering education should be evidence-based.

Quality of evidence: Seventeen studies were identified

that met the inclusion criteria for this systematic review. Of

these, 15 studies looked at knowledge of correct method use

or contraceptive risks and benefits, including side effects

and method effectiveness (45–59). All but one study (56)

found a statistically significant positive impact of educational

interventions on increased knowledge. These studies included

six randomized controlled trials with low risk for bias.

Potential consequences: Clients will make more informed

decisions when choosing a contraceptive method. More clients will

be satisfied with the process of selecting a contraceptive method.

Rationale: Knowledge obtained through educational

activities, as integrated into the larger counseling model, is

a critically important precondition for the client’s ability to

make informed decisions. The techniques described in the

recommendations have a well-established evidence base for

increasing knowledge and satisfaction with services. This

knowledge lays the foundation for further counseling steps that

will increase the likelihood of correct and consistent use, and

increased satisfaction will increase return visits to the service

site, as needed. Four of seven EWG members agreed to this

recommendation; three members did not express an opinion.

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

Contraceptive Services —

Confirm Understanding

Recommendation: A check box or written statement should

be available in the medical record that can be used to document

that the client expressed understanding of the most important

information about her/his chosen contraceptive method. The

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.

Documentation of understanding using the teach-back method

and a check box or written statement can be used in place of

a written method-specific informed consent.

Quality of evidence: Two studies from outside the family

planning literature (one cohort study and one controlled

trial with unclear randomization) (60,61) and a strong

recommendation by members of the Technical Panel on

Counseling and Education were considered.

Potential consequences: More clients will make informed

decisions, adherence to contraceptive and treatment plans will

improve, and reproductive and other health conditions will be

better controlled.

Rationale: Asking providers to document in the record

that the client is making an informed decision will increase

providers’ attention to this task. This recommendation will

replace a previous requirement that providers obtain method-

specific informed consent from each client (in addition to a

general consent form). Six of seven EWG members agreed to

this recommendation.

Adolescent Services —

Comprehensive Information

Recommendation: Providers should provide comprehensive

information to adolescent clients about how to prevent

pregnancy and STDs. This should include information about

contraception and that avoiding sex (abstinence) is an effective

way to prevent pregnancy and STDs.

Quality of evidence: A systematic review was not conducted

because other recent reviews were available that have shown a

substantial impact of comprehensive sexual health education

on reduced adolescent risk behavior (62–66). The evidence for

abstinence-only education was more limited: CDC’s Community

Guide concluded that there was insufficient evidence (67), but

the Department of Health and Human Services’ Office of

Adolescent Health has identified two abstinence-based programs

as having evidence of effectiveness (68).

Potential consequences: Teens will make more informed

decisions and will delay initiation of sexual intercourse. The

absence of harmful effects from comprehensive sexual health

education was noted.

Rationale: The benefits of informing adolescents about all ways

to prevent pregnancy are substantial. Ultimately, each adolescent

should make an informed decision that meets her or his unique

circumstances, based on the counseling provided by the provider.

Six of seven EWG members agreed to this recommendation.

Adolescent Services — Use of Long-

Acting Reversible Contraception

Recommendation: Education about contraceptive methods

should include an explanation that long-acting reversible

contraception is safe and effective for nulliparous women

(women who have not been pregnant or given birth), including

adolescents.

Quality of evidence: CDC guidelines on contraceptive use

(37) provide evidence that long-acting reversible contraception

is safe and effective for adolescents and nulliparous women.

Potential consequences: More providers will encourage

adolescents to consider long-acting reversible contraception;

more adolescents will choose long-acting reversible

contraception, resulting in reduced rates of teen pregnancy,

including rapid repeat pregnancy.

Rationale: Long-acting reversible contraception is safe for

adolescents (37). As noted above, providers should inform

clients about the most effective methods available. The

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.

Three EWG members agreed to this recommendation; two

EWG members abstained.

Adolescent Services —

Confidential Services

Recommendation: Confidential family planning services

should be made available to adolescents, while observing state

laws and any legal obligations for reporting.

Quality of evidence: Six descriptive studies documented

one or more of the following: that confidentiality is important

to adolescents; that many adolescents reported they will not

use reproductive health services if confidentiality cannot be

assured; and that adolescents might not be honest in discussing

reproductive health with providers if confidentiality cannot be

assured (69–74). One RCT showed a slight reduction in use of

services after receiving conditional confidentiality, compared

with complete confidentiality (75). One study showed a

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MMWR / April 25, 2014 / Vol. 63 / No. 4 39

positive association between confidentiality and intention to

use services (73).

Potential consequences: Consequences might include an

increased intention to use services, increased use of services, and

reduced rates of teen pregnancy. However, explaining the need

to report under certain circumstances (rape, child abuse) might

deter some adolescent clients from using services. Further, some

parents/guardians might not agree that adolescents should have

access to confidential services.

Rationale: Minors’ rights to confidential reproductive health

services are consistent with state and federal law. The risks of

not providing confidential services to adolescents are great and

likely to result in an increased rate of teen pregnancies. Finally,

this recommendation is consistent with the recommendations

of three professional medical associations that endorse

provision of confidential services to adolescents (76–78). All

seven EWG members agreed to this recommendation.

Adolescent Services —

Family-Child Communication

Recommendation: Providers should encourage and promote

family-child communication about sexual and reproductive health.

Quality of evidence: From the family planning literature,

16 parental involvement programs (most using an RCT study

design) were found to be positively associated with at least one

short-term (13 of 16 studies) or medium-term (four of seven

studies) outcome (79–94). However, only one of these studies

was linked to clinical services (80); others were implemented

in community settings.

Potential consequences: Consequences might include

increased parental/guardian involvement and communication,

improved knowledge/awareness, increased intentions to use

contraceptives, and the adoption of more pro-social norms

that support parent-child communication about sexual health.

Rationale: The literature provides strong evidence that

increased communication between a child and her/his parent/

guardian will lead to safer sexual behavior among teens,

and numerous community-based programs have created an

evidence base for how to strengthen parents/guardians’ ability

to hold those conversations. Although less is known about

how to do so in a clinical setting, providers can refer their

clients to programs in the community, and principles from the

community-based approaches can be used to help providers

develop appropriate approaches in the clinical setting. Research

in this area will be monitored, and the recommendations will be

revised, as needed. Four of five EWG members who provided

input agreed to this recommendation; one member abstained.

Adolescent Services —

Repeat Teen Pregnancy

Recommendation: Providers should refer pregnant and

parenting adolescents to home visiting and other programs

that have been shown to provide needed support and reduce

rates of repeat teen pregnancy.

Quality of evidence: Three of four studies of clinic-based

programs (using retrospective case-control cohort, ecological

evaluation, and prospective cohort study designs) showed that

comprehensive teen pregnancy prevention programs (programs

with clinical, school, case management, and community

components) were associated with both medium- and long-

term outcomes (95–98). In addition, several randomized trials

of community-based home visiting programs, and an existing

systematic review of the home visiting literature, demonstrated

a protective impact of these programs on preventing repeat teen

pregnancy and other relevant outcomes (99–103).

Potential consequences: Consequences might include

decreased rapid repeat pregnancy and abortion rates, and

increased use of contraceptives.

Rationale: There is sufficient evidence to recommend that

providers link pregnant and parenting teens to community and

social services that might reduce rates of rapid repeat pregnancy.

Three of seven EWG members agreed to an earlier version of

this recommendation. Other members wanted to remove a

clause about prioritizing the contraceptive needs of pregnant/

parenting teens because they felt that all clients should be

treated as priority clients. This suggestion was adopted, but

the EWG did not have a chance to vote again on the modified

recommendation.

Contraceptive Method Availability

Recommendation: Family planning programs should stock

and offer a broad a range of FDA-approved contraceptive

methods so that the needs of individual clients can be met.

These methods are optimally available on-site, but strong

referrals can serve to make methods not available on-site real

options for clients.

Quality of evidence: No research was identified that

explicitly addressed the question of whether having a broad

range of methods was associated with short-, medium-, or

long-term reproductive health outcomes. However, as noted

above, three descriptive studies from the review of quality

improvement literature identified contraceptive choice as an

important aspect of quality care (42–44).

Potential consequences: Consequences might include

increased use of contraception and increased use of reproductive

Recommendations and Reports

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

health services. It also was noted that there are sometimes high

costs to stocking certain methods (e.g., intrauterine devices

and contraceptive implants).

Rationale: Having a broad range of contraceptive methods is

central to client-centered care, a core aspect of providing quality

services. Individual clients need to have a choice so they can

select a method that best fits their particular circumstances.

This is likely to result in more correct and consistent use of

the chosen methods. The benefits of this recommendation

were weighed more heavily than the negative outcomes

(e.g., additional cost). All five EWG members agreed to this

recommendation.

Youth-Friendly Services

Recommendation: Family planning programs should take

steps to make services “youth-friendly.”

Quality of evidence: Of 20 studies that were identified,

six looked at short-, medium-, or long-term outcomes with

mixed designs (one group time series, one cross-sectional, three

prospective cohort, and one nonrandomized trial); protective

effects were found on long-term (two of three studies),

medium-term (three of three), and short-term (three of three)

outcomes (29,30,104–107). One of these six studies (29), plus

13 other descriptive studies (for a total of 14 studies), presented

adolescents’ or providers’ views on facilitators for adolescent

clients in using youth-friendly family planning services. Key

factors described were confidentiality (13 of 14), accessibility

(11 of 14), peer involvement (three of 14), parental or familial

involvement (four of 14), and quality of provider interaction

(11 of 14) (105–121). Four of these studies (111,112,114,121)

plus one other descriptive study (108) described barriers to

clinics adopting and implementing youth-friendly family

planning services.

Potential consequences: Consequences might include

increased use of reproductive health services by adolescents,

improved contraceptive use, use of more effective methods,

more consistent use of contraception, and reduced rates of teen

pregnancy. It is also likely to lead to improved satisfaction with

services and greater knowledge about pregnancy prevention

among adolescents. It is possible that there will be higher costs,

and some uncertainty regarding the benefits due to a relatively

weak evidence base.

Rationale: Existing evidence has demonstrated the

importance of specific characteristics to adolescents’ attitudes

and use of clinical services. The potential benefits of providing

youth-friendly services outweigh the potential costs and

weak evidence base. All five EWG members agreed to this

recommendation. Some thought that it should be cast as an

example of comprehensively client-centered care, rather than

an end of its own.

Quality Improvement

Recommendation: Family planning programs should have

a system for quality improvement, which is designed to review

and strengthen the quality of services on an ongoing basis.

Family planning programs should select, measure, and assess

at least one outcome measure on an ongoing basis, for which

the service site can be accountable.

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

quality family planning services (42–44,113,123–128). These

studies used a qualitative (k = 4) or cross-sectional (k = 6) study

design. Ten descriptive studies identified client and provider

perspectives on what constitutes quality family planning services,

which include stigma and embarrassment reduction (n = 9), client

access and convenience (n = 8); confidentiality (n = 3); efficiency

and tailoring of services (n = 6); client autonomy and confidence

(n = 5); contraceptive access and choice (n = 4); increased time

of patient-provider interaction (n = 3); communication and

relationship (n = 3); structure and facilities (n = 2); continuity

of care (n = 2). Well-established frameworks for guiding quality

improvement efforts were referenced (122,129–132).

Potential consequences: Consequences might include

increased use by clients of more effective contraceptive methods,

clients might be more likely to return for care, client satisfaction

might improve, and there might be reduced rates of teen and

unintended pregnancy, and improved spacing of births.

Rationale: Research, albeit limited, has demonstrated that

quality services are associated with improved client experience

with care and adoption of more protective contraceptive

behavior. Further, these recommendations on quality

improvement are consistent with those made by national leaders

in the quality improvement field. Research is either under way

or planned to validate a core set of performance measures, and

the recommendations will be updated as new findings emerge.

All five EWG members agreed to these recommendations.

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of quality among low-income women: racial, ethnic and language group

differences. Perspect Sex Reprod Health 2008;40:202–11.

124. Becker H, Stuifbergen A, Tinkle M. Reproductive health care

experiences of women with physical disabilities: a qualitative study.

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.

126. Dixon-Woods M, Stokes T, Young B, Phelps K, Windridge K, Shukla

R. Choosing and using services for sexual health: a qualitative study of

women’s views. Sex Transm Infect 2001;77:335–9.

127. Khan NS, Kirkman R. Intimate examinations: use of chaperones in

community-based family planning clinics. BJOG 2000;107:130–2.

128. Fiddes P, Scott A, Fletcher J, Glasier A. Attitudes towards pelvic

examination and chaperones: a questionnaire survey of patients and

providers. Contraception 2003;67:313–7.

129. Bruce J. Fundamental elements of the quality of care: a simple

framework. Stud Fam Plann 1990;21:61–91.

130. Donabedian A. The quality of care. JAMA 1988;260:1743–8.

131. Institute of Medicine. Crossing the quality chasm: a new health system for

the 21st century. Washington, DC: National Academies of Science; 2001.

132. National Quality Forum. ABCs of measurement. Washington, DC:

National Quality Forum; 2011. Available at http://www.qualityforum.

org/Measuring_Performance/ABCs_of_Measurement.aspx.

Recommendations and Reports

MMWR / April 25, 2014 / Vol. 63 / No. 4 45

Counseling is a process that enables clients to make

and follow through on decisions. Education is an integral

component of the counseling process that helps clients to

make informed decisions. Providing quality counseling is an

essential component of client-centered care.

Key principles of providing quality counseling are listed below

and may be used when providing family planning services. The

model was developed in consultation with the Technical Panel

on Contraceptive Counseling and Education and reviewed by

the Expert Work Group. Although developed specifically for

providing contraceptive counseling, the principles are broad and

can be applied to health counseling on other topics. Although

the principles are listed here in a particular sequence, counseling

is an iterative process, and at every point in the client encounter

it is necessary to determine whether it is important to readdress

and emphasize a given principle.

Principles of Quality Counseling

Principle 1. Establish and Maintain

Rapport with the Client

Establishing and maintaining rapport with a client is vital

to the encounter and achieving positive outcomes (1). This

can begin by creating a welcoming environment and should

continue through every stage of the client encounter, including

follow-up. The contraceptive counseling literature indicates

that counseling models that emphasized the quality of the

interaction between client and provider have been associated

with decreased teen pregnancy, increased contraceptive use,

increased use of more effective methods, increased use of repeat

or follow-up services, increased knowledge, and enhanced

psychosocial determinants of contraceptive use (2–5) .

Principle 2. Assess the Client’s Needs and

Personalize Discussions Accordingly

Each visit should be tailored to the client’s individual

circumstances and needs. Clients come to family planning

providers for various services and with varying needs.

Standardized questions and assessment tools can help providers

determine what services are most appropriate for a given visit

(6). Contraceptive counseling studies that have incorporated

standardized assessment tools during the counseling process

have resulted in increased contraceptive use, increased correct

Appendix C

Principles for Providing Quality Counseling

use of contraceptives, and increased use of more effective

methods (2,7,8). Contraceptive counseling studies that have

personalized discussions to meet the individual needs of

clients have been associated with increased contraceptive use,

increased correct use of contraceptives, increased use of more

effective methods, increased use of dual-method contraceptives

to prevent both sexually transmitted diseases (STDs) and

pregnancy, increased quality and satisfaction with services,

increased knowledge, and enhanced psychosocial determinants

of contraceptive use (4,7,9–12).

Principle 3. Work with the Client

Interactively to Establish a Plan

Working with a client interactively to establish a plan,

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

potential difficulties. The amount of time spent establishing a

plan will differ depending on the client’s purpose for the visit

and health-care needs. A client plan that requires behavioral

change should be made on the basis of the client’s own goals,

interests, and readiness for change (13–15). Use of computerized

decision aids before the appointment can facilitate this process

by providing a structured yet interactive framework for

clients to analyze their available options systematically and to

consider the personal importance of perceived advantages and

disadvantages (16,17). The contraceptive counseling literature

indicates that counseling models that incorporated goal

setting and development of action plans have been associated

with increased contraceptive use, increased correct use of

contraceptives, increased use of more effective methods, and

increased knowledge (2,9,18–20). Furthermore, contraceptive

counseling models that incorporated follow-up contacts

resulted in decreased teen pregnancy, increased contraceptive

use, increased correct use of contraceptives, increased use of

more effective methods, increased continuation of method

use, increased use of dual-method contraceptives to prevent

both STDs and pregnancy, increased use of repeat or follow-up

services, increased knowledge, and enhanced psychosocial

determinants of contraceptive use (2,3,7,11,21,22) . From the

family planning education literature, computerized decision

aids have helped clients formulate questions and have been

associated with increased knowledge, selection of more effective

methods, and increased continuation and compliance (23–25).

Recommendations and Reports

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

Principle 4. Provide Information That Can

Be Understood and Retained by the Client

Clients need information that is medically accurate,

balanced, and nonjudgmental to make informed decisions and

follow through on developed plans. When speaking with clients

or providing educational materials through any medium (e.g.,

written, audio/visual, or computer/web-based), the provider

must present information in a manner that can be readily

understood and retained by the client. Strategies for making

information accessible to clients are provided (see Appendix D).

Principle 5. Confirm Client Understanding

It is important to ensure that clients have processed the

information provided and discussed. One technique for

confirming understanding is to have the client restate the most

important messages in her or his own words. This teach-back

method can increase the likelihood of the client and provider

reaching a shared understanding, and has improved compliance

with treatment plans and health outcomes (26,27). Using the

teach-back method early in the decision-making process will

help ensure that a client has the opportunity to understand her

or his options and is making informed choices (28).

References

1. Lambert M. Implications of outcome research for psychotherapy

integration. In: Norcross J, Goldfind M, eds. Handbook of psychotherapy

integration. New York, NY: Basic Books; 1992:94–129.

2. Adams-Skinner J, Exner T, Pili C, Wallace B, Hoffman S, Leu CS. The

development and validation of a tool to assess nurse performance in dual

protection counseling. Patient Educ Couns 2009;76:265–71.

3. Brindis CD, Geierstanger SP, Wilcox N, McCarter V, Hubbard A.

Evaluation of a peer provider reproductive health service model for

adolescents. Perspect Sex Reprod Health 2005;37:85–91.

4. Nobili MP, Piergrossi S, Brusati V, Moja EA. The effect of patient-

centered contraceptive counseling in women who undergo a voluntary

termination of pregnancy. Patient Educ Couns 2007;65:361–8.

5. Proctor A, Jenkins TR, Loeb T, Elliot M, Ryan A. Patient satisfaction

with 3 methods of postpartum contraceptive counseling: a randomized,

prospective trial. J Reprod Med 2006;51:377–82.

6. Fiore M, Jaén C, Baker T, Bailey W, Benowitz N, Curry S. Treating

tobacco use and dependence: 2008 update. Clinical practice guideline.

Rockville, MD: US Department of Health and Human Services; 2008.

Available at http://www.ncbi.nlm.nih.gov/books/NBK63952.

7. Boise R, Petersen R, Curtis KM, et al. Reproductive health counseling

at pregnancy testing: a pilot study. Contraception 2003;68:377–83.

8. Custo G, Saitto C, Cerza S, Sertoli G. The adjusted contraceptive score

(ACS) improves the overall performance of behavioural and barrier

contraceptive methods. Adv Contracept Deliv Syst 1987;3:367–73.

9. Hanna KM. Effect of nurse-client transaction on female adolescents’

oral contraceptive adherence. Image J Nurs Sch 1993;25:285–90.

10. Schunmann C, Glasier A. Specialist contraceptive counselling and

provision after termination of pregnancy improves uptake of long-acting

methods but does not prevent repeat abortion: a randomized trial. Hum

Reprod 2006;21:2296–303.

11. Shlay JC, Mayhugh B, Foster M, Maravi ME, Baron AE, Douglas JM

Jr. Initiating contraception in sexually transmitted disease clinic setting:

a randomized trial. Am J Obstet Gynecol 2003;189:473–81.

12. Weisman CS, Maccannon DS, Henderson JT, Shortridge E, Orso CL.

Contraceptive counseling in managed care: preventing unintended

pregnancy in adults. Womens Health Issues 2002;12:79–95.

13. Kaplan D. Family Counseling for all counselors. Greensboro, NC: CAPS

Publications; 2003.

14. Nupponen R. What is counseling all about—basics in the counseling

of health-related physical activity. Patient Educ Couns 1998;

33(Suppl):S61–7.

15. Whitlock EP, Orleans CT, Pender N, Allan J. Evaluating primary care

behavioral counseling interventions: an evidence-based approach. Am

J Prev Med 2002;22:267–84.

16. French RS, Wellings K, Cowan F. How can we help people to choose a

method of contraception? The case for contraceptive decision aids. J Fam

Plann Reprod Health Care 2009;35:219–20.

17. O’Connor AM, Bennett CL, Stacey D, et al. Decision aids for people

facing health treatment or screening decisions. Cochrane Database Syst

Rev 2009;CD001431.

18. Cowley CB, Farley T, Beamis K. “Well, maybe I’ll try the pill for just a

few months...”: brief motivational and narrative-based interventions to

encourage contraceptive use among adolescents at high risk for early

childbearing. Fam Syst Health 2002;20:183–204.

19. Gilliam M, Knight S, McCarthy M Jr. Success with oral contraceptives:

a pilot study. Contraception 2004;69:413–8.

20. Namerow PB, Weatherby N, Williams-Kaye J. The effectiveness of

contingency-planning counseling. Fam Plann Perspect 1989;21:115–9.

21. Berger DK, Perez G, Kyman W, et al. Influence of family planning

counseling in an adolescent clinic on sexual activity and contraceptive

use. J Adolesc Health Care 1987;8:436–40.

22. Winter L, Breckenmaker LC. Tailoring family planning services to the

special needs of adolescents. Fam Plann Perspect 1991;23:24–30.

23. Chewning B, Mosena P, Wilson D, et al. Evaluation of a computerized

contraceptive decision aid for adolescent patients. Patient Educ Couns

1999;38:227–39.

24. Garbers S, Meserve A, Kottke M, Hatcher R, Chiasson MA. Tailored health

messaging improves contraceptive continuation and adherence: results from

a randomized controlled trial. Contraception 2012;86:536–42.

25. Garbers S, Meserve A, Kottke M, Hatcher R, Ventura A, Chiasson MA.

Randomized controlled trial of a computer-based module to improve

contraceptive method choice. Contraception 2012;86:383–90.

26. McMahon SR, Rimsza ME, Bay RC. Parents can dose liquid medication

accurately. Pediatrics 1997;100:330–3.

27. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician

communication with diabetic patients who have low health literacy. Arch

Intern Med 2003;163:83–90.

28. National Quality Forum. Health literacy: a linchpin in achieving national

goals for health and healthcare, Issue Brief #13 2009. Available at http://www.

qualityforum.org/Publications/2009/03/Health_Literacy__A_Linchpin_in_

Achieving_National_Goals_for_Health_and_Healthcare.aspx.

Recommendations and Reports

MMWR / April 25, 2014 / Vol. 63 / No. 4 47

Providers should counsel clients about the effectiveness

of different contraceptive methods.Method effectiveness

is measured as the percentage of women experiencing an

Appendix D

Contraceptive Effectiveness

TABLE. Percentage of women experiencing an unintended pregnancy during the first year of typical use* and the first year of perfect use

†

contraception and the percentage continuing use at the end of the first year — United States

Method

% of women experiencing an unintended pregnancy

within the first year of use

% of women continuing use at 1 year

Typical use Perfect use

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.

unintended pregnancy during the first year of use, and is

estimated for both typical and perfect use (Table).

Recommendations and Reports

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

The client should receive and understand the information

she or he needs to make informed decisions and follow

treatment plans. This requires careful attention to how

information is communicated. The following strategies can

make information more readily comprehensible to clients:

Strategies for Providing Information to Clients

Educational materials should be provided that are clear and

easy to understand. Educational materials delivered through

any one of a variety of media (for example, written, audio/

visual, computer/web-based) need to be presented in a format

that is clear and easy to interpret by clients with a 4th to 6th

grade reading level (1–3). Many adults have only a basic

ability to obtain, process, and understand health information

necessary to make decisions about their health (4). Making

easy-to-access materials enhances informed decision-making

(1–3). Test all educational materials with the intended

audiences for clarity and comprehension before wide-scale use.

The following evidence-based tools provide recommendations

for increasing the accessibility of materials through careful

consideration of content, organization, formatting, and

writing style:

• Health Literacy Universal Precautions Toolkit, provided

by the Agency for Healthcare Research and Quality

(available at http://www.ahrq.gov/qual/literacy),

• Toolkit for Making Written Material Clear and Effective,

provided by the Centers for Medicare and Medicaid Services

(available at http://www.cms.gov/WrittenMaterialsToolkit),

and

• Health Literacy Online, provided by the Office of Disease

Prevention and Health Promotion (available at http://

www.health.gov/healthliteracyonline).

Information should be delivered in a manner that is

culturally and linguistically appropriate. In presenting

information it is important to be sensitive to the client’s

cultural and linguistic preferences (5,6). Ideally information

should be presented in the client’s primary language, but

translations and interpretation services should be available

when necessary. Information presented must also be culturally

appropriate, reflecting the client’s beliefs, ethnic background,

and cultural practices. Tools for addressing cultural and

linguistic differences and preferences include

• Health Literacy Universal Precautions Toolkit, provided

by the Agency for Healthcare Research and Quality

(available at http://www.ahrq.gov/qual/literacy), and

Appendix E

Strategies for Providing Information to Clients

• Toolkit for Making Written Material Clear and Effective,

Part 11; Understanding and using the “Toolkit Guidelines

for Culturally Appropriate Translation,” provided by the

Centers for Medicare and Medicaid Services (available at

http://www.cms.gov/outreach-and-education/outreach/

writtenmaterialstoolkit/downloads/toolkitpart11.pdf).

The amount of information presented should be limited and

emphasize essential points. Providers should focus on needs

and knowledge gaps identified during the assessment. Many

clients immediately forget or remember incorrectly much of

the information provided. This problem is exacerbated as

more information is presented (7–9). Limiting the amount

of information presented and highlighting important facts

by presenting them first improves comprehension (10–14).

Numeric quantities should be communicated in a way that

is easily understood. Whenever possible, providers should use

natural frequencies and common denominators (for example,

85 of 100 sexually active women are likely to get pregnant

within 1 year using no contraceptive, as compared with 1

in 100 using an IUD or implant), and display quantities in

graphs and visuals. Providers also should avoid using verbal

descriptors without numeric quantities (for example, sexually

active women using an IUD or implant almost never become

pregnant). Finally, they should quantify risk in absolute rather

than relative terms (for example, “the chance of unintended

pregnancy is reduced from 8 in 100 to 1 in 100 by switching

from oral contraceptives to an IUD” versus the chance of

unintended pregnancy is reduced by 87%). Numeracy is more

highly correlated with health outcomes than the ability to read

or listen effectively (15). The strategies listed above can help

clients interpret numeric quantities correctly (16–28).

Balanced information on risks and benefits should be

presented and messages framed positively. In addition to

discussing risks, contraindications, and warnings, providers

should discuss the advantages and benefits of contraception.

In presenting this information, providers should express risks

and benefits in a common format (for example, do not present

risks in relative terms and benefits in absolute terms), and frame

messages in positive terms (for example “99 out of 100 women

find this a safe method with no side effects,” versus “1 out of

100 women experience noticeable side effects”). Many clients

prefer to receive a balance of information on risks and benefits

(29), and using a common format avoids bias in presentation

of information (

18,22,26,30). Framing messages positively

increases acceptance and comprehension (18,22,31,32).

Recommendations and Reports

MMWR / April 25, 2014 / Vol. 63 / No. 4 49

Active client engagement should be encouraged. Providers

should use educational materials that encourage active

information processing (e.g., questions, quizzes, fill-in-the-

blank, web-based games, and activities). In addition, they

should be sure the client has an opportunity to discuss the

information provided, and when speaking with a client,

providers should engage her or him actively. Research has

indicated that interactive materials improve knowledge

of contraceptive risks, benefits, and correct method use

(33–35). Clients also value spoken information (29,36); and

educational materials, when delivered by a provider, more

effectively increase knowledge (10,37). In particular, presenting

information in a question and answer format is more effective

than simply presenting the information (10,15,37–41).

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2007;21:115–24.

36. Grime J, Blenkinsopp A, Raynor DK, Pollock K, Knapp P. The role and

value of written information for patients about individual medicines: a

systematic review. Health Expect 2007;10:286–98.

Recommendations and Reports

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

37. DeLamater J, Wagstaff DA, Havens KK. The impact of a culturally

appropriate STD/AIDS education intervention on black male

adolescents’ sexual and condom use behavior. Health Educ Behav

2000;27:454–70.

38. McMahon SR, Rimsza ME, Bay RC. Parents can dose liquid medication

accurately. Pediatrics 1997;100:330–3.

39. Belcher L, Kalichman S, Topping M, et al. A randomized trial of a brief

HIV risk reduction counseling intervention for women. J Consult Clin

Psychol 1998;66:856–61.

40. Eldridge GD, St Lawrence JS, Little CE, et al. Evaluation of the HIV

risk reduction intervention for women entering inpatient substance

abuse treatment. AIDS Educ Prev 1997;9(Suppl):62–76.

41. Jaccard J. Unlocking the contraceptive conundrum. Washington, DC:

The National Campaign to Prevent Teen and Unplanned Pregnancy;

2009. Available at http://thenationalcampaign.org/resource/

unlocking-contraception-conundrum.

Recommendations and Reports

MMWR / April 25, 2014 / Vol. 63 / No. 4 51

The following services have been given a D recommendation

from the U.S. Preventive Services Task Force (USPSTF), which

indicates that the potential harms of routine screening outweigh

the benefits. Providers should not perform these screening services.

The USPSTF has recommended against offering the

following services to women and men:

• Asymptomatic bacteriuria: USPSTF recommends

against screening for asymptomatic bacteriuria in men

and nonpregnant women (1).

• Gonorrhea: USPSTF recommends against routine

screening for gonorrhea infection in men and women who

are at low risk of infection (2).

• Hepatitis B: USPSTF recommends against routinely

screening the general asymptomatic population for

chronic hepatitis B virus infection (3).

• Herpes simplex virus (HSV): USPSTF recommends

against routine serological screening for HSV in

asymptomatic adolescents and adults (4).

• Syphilis: USPSTF recommends against screening of

asymptomatic persons who are not at increased risk of

syphilis infection (5).

The USPSTF has recommended against offering the

following services to women:

• BRCA mutation testing for breast and ovarian cancer

susceptibility: USPSTF recommends against routine

referral for genetic counseling or routine breast cancer

susceptibility gene (BRCA) testing for women whose family

history is not associated with an increased risk of deleterious

mutations in breast cancer susceptibility gene 1 (BRCA1) or

breast cancer susceptibility gene 2 (BRCA2) (6). However,

USPSTF continues to recommend that women whose family

history is associated with an increased risk of deleterious

mutations in BRCA1 or BRCA2 genes be referred for genetic

counseling and evaluation for BRCA testing.

• Breast self-examination: USPSTF recommends against

teaching breast self-examination (7).

• Cervical cytology: USPSTF recommends against routine

screening for cervical cancer with cytology (Pap smear) in

the following groups: women aged <21 years, women aged

>65 years who have had adequate prior screening and are

not otherwise at high risk for cervical cancer, women who

have had a hysterectomy with removal of the cervix and

who do not have a history of a high-grade precancerous

lesion (i.e., cervical intraepithelial neoplasia grade 2 or 3)

or cervical cancer. USPSTF recommends against screening

for cervical cancer with HPV testing, alone or in

combination with cytology, in women aged <30 years (8).

Appendix F

Screening Services For Which Evidence Does Not Support Screening

• Ovarian cancer: USPSTF recommends against routine

screening for ovarian cancer (9).

The USPSTF has recommended against offering the

following services to men:

• Prostate cancer: USPSTF recommends against prostate-

specific antigen (PSA)-based screening for prostate cancer (10).

• Testicular cancer: USPSTF recommends against screening

for testicular cancer in adolescent or adult males (11).

References

1. US Preventive Services Task Force. Screening for asymptomatic bacteriuria

in adults. Rockville, MD: US Department of Health and Human Services,

Agency for Healthcare Research and Quality; 2008. Available at http://

www.uspreventiveservicestaskforce.org/uspstf/uspsbact.htm.

2. US Preventive Services Task Force. Screening for gonorrhea. Rockville,

MD: US Department of Health and Human Services, Agency for

Healthcare Research and Quality; 2005. Available at http://www.

uspreventiveservicestaskforce.org/uspstf/uspsgono.htm.

3. US Preventive Services Task Force. Screening for hepatitis B infection.

Rockville, MD: US Department of Health and Human Services, Agency

for Healthcare Research and Quality; 2004. Available at http://www.

uspreventiveservicestaskforce.org/uspstf/uspshepb.htm.

4. US Preventive Services Task Force. Screening for genital herpes:

recommendation statement. Rockville, MD: US Department of Health

and Human Services, Agency for Healthcare Research and Quality;

2005. Available at http://www.uspreventiveservicestaskforce.org/

uspstf05/herpes/herpesrs.htm.

5. US Preventive Services Task Force. Screening for syphilis infection.

Rockville, MD: US Department of Health and Human Services, Agency

for Healthcare Research and Quality; 2004. Available at http://www.

uspreventiveservicestaskforce.org/uspstf/uspssyph.htm.

6. US Preventive Services Task Force. Risk assessment, genetic counseling, and

genetic testing for BRCA-related cancer in women. Rockville, MD: US

Department of Health and Human Services, Agency for Healthcare Research

and Quality; 2013. Available at http://www.uspreventiveservicestaskforce.

org/uspstf/uspsbrgen.htm.

7. US Preventive Services Task Force. Screening for breast cancer. Rockville,

MD: US Department of Health and Human Services, Agency for

Healthcare Research and Quality; 2009. Available at http://www.

uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm.

8. US Preventive Services Task Force. Screening for cervical cancer.

Rockville, MD: US Department of Health and Human Services, Agency

for Healthcare Research and Quality; 2012. Available at www.

uspreventiveservicestaskforce.org/uspstf11/cervcancer/cervcancerrs.htm.

9. US Preventive Services Task Force. Screening for ovarian cancer: U.S.

Preventive Services Task Force reaffirmation recommendation statement.

Rockville, MD: US Department of Health and Human Services, Agency

for Healthcare Research and Quality; 2012. Available at http://www.

uspreventiveservicestaskforce.org/uspstf12/ovarian/ovarcancerrs.htm.

10. US Preventive Services Task Force. Screening for prostate cancer.

Rockville, MD: US Department of Health and Human Services, Agency

for Healthcare Research and Quality; 2012. Available at http://www.

uspreventiveservicestaskforce.org/prostatecancerscreening.htm.

11. US Preventive Services Task Force. Screening for testicular cancer.

Rockville, MD: US Department of Health and Human Services, Agency

for Healthcare Research and Quality; 2011. Available at http://www.

uspreventiveservicestaskforce.org/uspstf/uspstest.htm.

Recommendations and Reports

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

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

Arik V. Marcell, MD, The Johns Hopkins University and the Male Training Center

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

Jacki Witt, MSN, Clinical Training Center for Family Planning, University of Missouri—Kansas City

Recommendations and Reports

MMWR / April 25, 2014 / Vol. 63 / No. 4 53

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

Arik V. Marcell, MD, The Johns Hopkins University and the Male Training Center

Elissa Meites, MD, Division of STD Prevention, CDC

Anne Rompalo, MD, Johns Hopkins University

Thomas Walsh, MD, University of Washington Medical Center

Jacki Witt, MSN, Clinical Training Center for Family Planning, University of Missouri—Kansas City

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

Arik V. Marcell, MD, The Johns Hopkins University and the Male Training Center

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

Recommendations and Reports

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

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 Oce of Population Aairs 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.

ISSN: 1057-5987

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