Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696592580260.pdf (United States)
SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES FOR ADOLESCENTS AND ADULTS Focusing on contraception care and preventing, screening and testing for STIs and HIV This guide sets forth best practices for sexual and reproductive health.

It focuses on contraceptive care and the prevention, screening and testing of sexually transmitted infections (STIs) and HIV.
It is intended as a reference tool for health care providers in settings such as Primary Care, Internal Medicine, Urgent/ Emergency Care, Family Medicine, Pediatrics, Adolescent Health, Family Planning, Abortion Care, Gynecology, Labor and Delivery, Obstetrics/Maternal-Fetal Medicine and Pre/Postpartum Care.
Providers are encouraged to meet these best practices while creating their own innovative health care quality improvement strategies that place patients’ unique cultures, experiences and preferences at the center of care.

The following resources are useful supplements to this guide: • The Centers for Disease Control and Prevention (CDC)'s 2015 Sexually Transmitted Diseases Treatment Guidelines • The CDC’s United States Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2010 • The U.S.
Selected Practice Recommendations for Contraceptive Use, 2013 Find these and other reference materials under “Tools and Resources.” Advancing Sexual and Reproductive Justice The New York City Health Department envisions a city where all New Yorkers can safely express their sexuality and gender identity with dignity, possessing the knowledge, skills and resources to support healthy and fulfilling lives.
Leading with a Sexual and Reproductive Justice approach means promoting every individual’s human right to: • Decide if and when to have a child and the conditions under which to give birth • Decide if and when to not have a child and the options for preventing or ending a pregnancy • Parent the children they have with the necessary social supports in safe environments and healthy communities, and without threat of violence from individuals, organizations or the government • Bodily autonomy or self-expression and agency free from any form of sexual or reproductive oppression In addition to promoting evidence-based clinical practices, this guidance stresses a commitment to the above values.
The Sexual and Reproductive Health Care Best Practices for Adolescents and Adults were developed by the New York City Health Department and have been endorsed by: • Association of Reproductive Health • New York Civil Liberties Union Professionals (ARHP) • New York State American Academy • Heilbrunn Department of Population and Family of Pediatrics, Chapters 2 & 3 Health, Mailman School of Public Health at Columbia University • National Abortion Federation (NAF) • NYC Health + Hospitals • Physicians for Reproductive Health 2 SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES Policy and Practice Recommendations 1 Provide patient-centered and culturally sensitive care to assess and meet patients’ sexual and reproductive health needs.
A.

Individuals and families make decisions about contraception, pregnancy, childbirth, breastfeeding and birth spacing in the context of many personal and cultural factors.

Conduct patient-centered care—care guided by patients’ unique circumstances and preferences—while offering unbiased, evidence-based information.

B.

Refrain from making assumptions about patients' sexual orientation and gender identity and expression based on external appearances.

This information should come only from the patient.
Recognize that self-identification and behaviors do not always align.

C. Use culturally responsive language, including self-designated pronouns, to affirm patients' gender identity and expression.

This applies to paper and electronic forms and medical records, to the fullest extent possible.

Contraception Terms in this Guide: Throughout this document, “hormonal IUDs” refers to any of the device trade names Mirena®, Skyla® and Liletta™.
The term “non-hormonal IUD” refers to ParaGard®, also known as the copper IUD.

Unless otherwise specified, “IUD” or “IUDs” refers to both hormonal and non-hormonal devices.

“Implant” refers to Nexplanon®.

Oral contraceptives (either combined hormonal or progestin- only types) refer to “the pill” or “pills,” and “the patch” refers to Ortho Evra®.

The term “vaginal ring” refers to NuvaRing®, and “the shot” refers to the trade name Depo-Provera®, also known as the contraceptive injection, depo or DMPA.
SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES 3 D. Ensure a private setting is made available for discussing patients’ sexual history and sexual and reproductive health needs.

i.
i.

Robust, sensitive and inclusive sexual history- taking is crucial to determining the sexual and reproductive health needs of patients, particularly LGBTQ (lesbian, gay, bisexual, transgender, queer or questioning) patients, who may not volunteer relevant information as readily as heterosexual and cisgender patients.1-4 E. Take a brief sexual history at every visit, beginning at age 12, to identify needs for education, counseling, contraception, STI and HIV screening and testing, and similar services.
F. Take a comprehensive sexual history at least annually.5-10 G. Use patient-centered, trauma-informed counseling strategies that support patients in making decisions free of provider bias, pressure or coercion.7, 8, 11, 12 H. Routinely assess adolescent and adult female and male patients, including LGBTQ patients, for intimate partner violence, sexual abuse and assault.

If a patient discloses these experiences, offer resources and treat the patient or refer for prompt treatment.

I.
I.

Screen patients for reproductive coercion in their intimate relationships, and refer patients to appropriate resources.13-18 J.

Regardless of the initial reason for the visit, address any identified sexual and reproductive health needs on the day of service, without delaying until a follow-up visit.

2 Ensure the confidentiality of sexual and reproductive health care, including contraception provision.

A.
A.

Provide sexual and reproductive health services to adolescent patients who are capable of consenting independently for such care without parental permission, in accordance with applicable laws and regulations.a i. NY Pub.

Health Law: § 2305(2); § 2504(3); § 2780(5); § 2781 a NY Pub.
Health Law § 2305(2): A licensed physician, or in a hospital, a staff physician, may diagnose, treat or prescribe for a person under the age of twenty-one years without the consent or knowledge of the parents or guardian of said person, where such person is infected with a sexually transmitted disease, or has been exposed to infection with a sexually transmitted disease.

NY Pub.
NY Pub.

Health Law § 2504(3): Any person who is pregnant may give effective consent for medical, dental, health and hospital services relating to prenatal care.

NY Pub.
NY Pub.

Health Law § 2780(5): "Capacity to consent" means an individual's ability, determined without regard to the individual's age, to understand and appreciate the nature and consequences of a proposed health care service, treatment, or procedure, or of a proposed disclosure of confidential HIV related information, as the case may be, and to make an informed decision concerning the service, treatment, procedure or disclosure.

NY Soc.

Serv.
NY Soc.

Serv.

Law §350(1)(e): Any inconsistent provisions of this title notwithstanding, so long as federal law and regulations require, family planning services and supplies shall be offered and promptly furnished to eligible persons of childbearing age, including children who can be considered sexually active, who desire such services and supplies, in accordance with the regulations of the department.
In order to maximize federal financial participation, the department may require that such services shall be furnished under title eleven of article five.

No person shall be compelled or coerced to accept such services or supplies.

NY Soc.

Serv.
NY Soc.

Serv.

Law 365-a(3)(d): Any inconsistent provisions of this section notwithstanding, medical assistance shall include: […](d) family planning services and supplies for eligible persons of childbearing age, including children under twenty-one years of age who can be considered sexually active, who desire such services and supplies, in accordance with the requirements of federal law and regulations and the regulations of the department.
No person shall be compelled or coerced to accept such services or supplies.

See also, e.g., 42 USCA §1396d(a)(4)(C); 18 NYCRR §§463.1, 463.6 and 505.13-applicants for or recipients of public assistance, recipients of Medicaid, and recipients of supplemental security income.

See also 42 CFR §59.5(a) - Title X family planning projects.

4 SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES ii.

U.S. Code Title 42: §1396d(a)(4)(C) iii.

NY Soc.

Serv.

Law: 350(1)(e); 365-a(3)(d) iv.


NY Codes, Rules and Regulations Title 18: 463.1; 463.6; 505.13 v. Code of Federal Regulations Title 42: 59.5(a) B.

Provide sexual and reproductive health services to all patients in accordance with applicable laws and regulations.19-21 C. Protect all patients’ confidentiality in administrative, (e.g., billing, appointment reminders, lab results reporting), registration and other front desk procedures.
D. Routinely collect confidential contact information from patients.19, 20, 22 E. Provide consenting patients with adequate time alone to discuss sexual and reproductive health and other potentially sensitive health topics.

3 Adhere to evidence-based guidance on contraceptive counseling, provision and follow-up care.

A.

Provide patient-centered counseling and education materials about the full range of FDA-approved contraceptive methods and STI and HIV prevention methods.

B.
B.

Recommend dual method use—condoms for STI and HIV prevention and an additional contraceptive method that the patient determines is best for them.7, 8 C. Dispense or prescribe the full range of FDA-approved contraceptive methods (including condoms, oral contraceptive pills, the patch, the ring, the shot, IUDs and implants), and offer referrals for methods not available on site.7, 8, 23-26 i.

Provide on-site access to ample condoms that patients can take privately and without having to ask.
Prescribe additional condoms to patients whose insurance will cover the cost.

ii.

Order free male and female condoms from the New York City Health Department for dispensing in health care settings.

D. Do not require pelvic examinations as a condition of contraception provision unless clinically indicated; see also recommendations regarding urine-based STI testing.7, 8 E. For patients who request an IUD and need STI testing, the IUD insertion should not be delayed while waiting for test results.
The STI testing specimens can be collected during the IUD insertion.

i.

If the patient has elected to receive an IUD and the cervix shows signs of acute infection (e.g., purulent cervical discharge), treat the infection and delay IUD insertion.23, 25 Offer alternative contraceptive methods until the infection is fully treated and the IUD can be safely inserted.

ii.
ii.

IUDs may be safely used in patients with a history of ectopic pregnancy and/or STIs.23 F. All methods of contraception, including IUDs and the implant, may be initiated the same day as the patient’s visit (“Quick Start”), unless delaying insertion is clinically indicated or the patient does not want the method initiated the same day as the visit.
Same-day contraception initiation is safe at any point during the menstrual cycle, as long as the provider is reasonably sure the patient is not pregnant.7, 8, 25 SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES 5 G. When prescribing contraceptives, offer the maximum supply as dictated by patient’s third-party payer.

Additionally, prescribe refills to last at least 12 months.25 For Depo-Provera, an annual prescription includes one unit and three refills.
For patients without insurance, see Best Practice #5.

H. Recommend patients who initiate a contraceptive method to return for follow-up visits as indicated.

Work with front desk/administrative staff to ensure that patients have the opportunity to schedule future follow-up appointments before they leave the office.25 i.
For adolescent patients who initiate any form of contraception, schedule a follow- up visit within one to three months, and schedule regular follow-up visits thereafter to discuss patients’ satisfaction with method, adherence, side effects and complications.27 ii.

For patients who initiate the IUD or implant, schedule post-insertion follow-up visits with a provider if indicated (e.g., if they encounter problems or side effects, have questions about the method or wish to change methods).
Encourage patients to contact their provider if they have questions or concerns about side effects prior to the scheduled follow-up visit.

iii.

For patients requesting an IUD or implant, ensure that they have information about device removal, including whether your facility offers removal appointments.

iv.

For adult patients who initiate any method, recommend that they return if they encounter problems or side effects, have questions or wish to change methods.
Unless otherwise indicated, no routine follow-up visit is necessary.25, 26 v. For patients who initiate the shot, schedule a follow-up visit within 12 to 14 weeks for the next injection.25 I. Adhere to current guidance on providing emergency contraception (EC).

i.

As indicated, offer advance provision of EC, including a prescription for ulipristal acetate (brand name ella®) to all patients.7, 8 ii.
The copper IUD has been found to be the most effective form of emergency contraception if inserted within five days of unprotected sex.28 J.

Provide pregnancy testing as indicated and if requested by patient, regardless of last menstrual period.25 6 SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES B. Adhere to current guidance on HIV prevention, testing and treatment.7, 8, 29, 34, 35, c i.

Offer HIV testing to all patients ages 13 to 64 per NY Public Health Law §2781-a.
• Offer testing annually or more frequently to patients determined to be at ongoing risk of infection.7, 8, 29 ii.

Offer HIV testing via oral consent process; informed consent may now be obtained verbally when ordering any HIV test.35, 36 iii.

For patients at ongoing behavioral or epidemiologic risk for HIV, offer pre-exposure prophylaxis (PrEP) antiretroviral medication or referral to a PrEP-experienced site.

4 Adhere to evidence-based guidance on STI prevention, testing and treatment.

A.
A.

Follow current clinical guidelines on STI prevention, testing and treatment for patients based on age, pregnancy status, sexual history and other risk factors.7, 8, 29, 30 i.

Annual screening for C. trachomatis (chlamydia) and N. gonorrhoeae (gonorrhea) is recommended for all sexually active females ages <25.

ii.

Use urine-based testing when possible to avoid unnecessary pelvic exams or urethral swab collection.29 iii.
As indicated, counsel patients on partner notification, and discuss notification options that protect the safety and well-being of both the patient and their partner(s).31, 32 iv.

Offer expedited partner therapy for chlamydia when appropriate.29, 33b • As of May 2016, New York State Department of Health has waived the electronic prescribing mandate for expedited partner therapy treatment.

The waiver will remain in effect until March 26, 2017.
• See also: NY Public Health Law §2312; §281(3); §3334 and §3337 • See also: NY Education Law §6810 • See also: NY Codes, Rules and Regulations Title 10: §23.5 b NY Pub.

Health Law §2312: Expedited partner therapy for chlamydia trachomatis infection.

NY Pub.

Health Law §281(3): Article 2-A –Prescription forms, electronic prescribing and language assistance.

NY Pub.

Health Law §3334: Emergency oral prescriptions for schedule II drugs and certain other controlled substances.

NY Pub.
NY Pub.

Health Law §3337: Oral prescriptions schedule III, IV and V substances.

NY Education Law §6810: Prescriptions.

NY Codes, Rules and Regulations Title 10: §23.5: c NY Pub.

Health Law § 2781: HIV related testing.

NY Pub.

Health Law § 2781-a: Required offering of HIV related testing.

1.
Every individual between the ages of thirteen and sixty-four years (or younger or older if there is evidence or indication of risk activity) who receives health services as an inpatient or in the emergency department of a general hospital defined in subdivision ten of section twenty-eight hundred one of this chapter or who receives primary care services in an outpatient department of such hospital or in a diagnostic and treatment center licensed under article twenty-eight of this chapter or from a physician, physician assistant, nurse practitioner, or midwife providing primary care shall be offered an HIV related test unless the health care practitioner providing such services reasonably believes that (a) the individual is being treated for a life threatening emergency; or (b) the individual has previously been offered or has been the subject of an HIV related test (except that a test shall be offered if otherwise indicated); or (c) the individual lacks capacity to consent to an HIV related test.
2.

As used in this section, "primary care" means the medical fields of family medicine, general pediatrics, primary care gynecology, without regard to board certification.

3.

The offering of HIV related testing under this section shall be culturally and linguistically appropriate in accordance with rules and regulations promulgated by the commissioner.

4.
4.

This section shall not affect the scope of practice of any health care practitioner or diminish any authority or legal or professional obligation of any health care practitioner to offer an HIV related test or to provide services or care for the subject of an HIV related test.

SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES 7 5 Remove barriers to care.

A.

Stock contraception and other sexual health emergency medications (like PEP) on site in clinical areas or pharmacies for immediate provision.
B.

Use appointment systems and patient flow procedures to accommodate patients (e.g., offer care during non-school hours for adolescents, offer walk-in services, etc.).

C. Use communication technologies consistent with patients’ preferred modes of communication and regulations of health care facilities (e.g., text message appointment reminders).
D. Know where to refer the patient for free or low-cost sexual and reproductive health care services (e.g., Title X service sites) if there are services you do not provide.39 i.

Title X service sites can be identified through the Office of Population Affairs Title X Family Planning Database.
E. Facilitate uninsured patients’ enrollment in available insurance options, including presumptive eligibility for the New York State Family Planning Benefit Program (FPBP), Family Planning Extension Program (FPEP) and Medicaid (for pregnant patients).

i. Uninsured patients may qualify for health insurance options through the NY State of Health insurance plan marketplace.

F. Actively manage payment and billing to cover costs of services provided: i.
Utilize government insurance resources; for current guidelines on health insurance policies and programs, consult the Centers for Medicare and Medicaid Standards and/or NY State Department of Health information on patient eligibility and enrollment.

iv.

For HIV-negative patients who report recent exposure to HIV, offer post-exposure prophylaxis medication (PEP) or referral to a PEP-experienced site.
v. As indicated, counsel patients on partner notification, and discuss notification options that protect the safety and well-being of both the patient and their partner(s).31, 34, 37 C. Offer age-and population-appropriate vaccines.38 i.
The HPV vaccine is recommended for: • All youthd aged 11-12 years • Females aged 13 to 26 • Males aged 13 to 21 who haven't previously been vaccinated • High-risk males (including men who have sex with men and patients with HIV) aged 22 to 26 who haven't previously been vaccinated ii.

For more information, consult City of New York and CDC resources.
d Amendments were proposed in the November 25, 2015 New York State Register, proposing to amend Part 23 of the State Sanitary Code regarding sexually transmitted diseases, authorizing health care practitioners to administer HPV vaccine to minors without the consent or knowledge of the minor’s parent or guardian.

[10 NYCRR §23.4].
The regulations have been filed with the Secretary of State, and they became effective upon publication of the Notice of Adoption in the State Register on May 18, 2016.The Regulatory Impact Statement that is being published with the Part 23 regulation amendments states: “Section 23.4 permits health care providers to prescribe and administer HPV vaccine to sexually active minors during confidential sexual and reproductive health care visits without consent or knowledge of the parent or guardian.” 8 SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES 6 Build staff capacity to serve patients of different ages, cultural backgrounds, sexual orientations and gender identities.
A.

When hiring, include interview questions to assess candidates’ comfort with and enthusiasm for providing sexual and reproductive health services, including to teens, and regardless of sexual orientation and gender identity.

B.

Prepare all staff to meet patients’ special needs via annual training in: i. Adolescents’ rights regarding sexual and reproductive health and behavioral and mental health, including confidentiality ii.
Customer service training for front-line staff that addresses minors’ rights to sexual health care, confidentiality, friendliness toward teens and comprehensive, medically accurate information about sexual and reproductive health services iii.

Cultural competence, with emphasis on the institutional and structural causes of health disparities iv.

Language access services and care considerations for patients with limited English proficiency v. Special considerations for LGBTQ patients, including youth ii.
Utilize commercial insurance.

iii.

Participate in the 340B drug pricing program to obtain contraceptive devices at discounted prices, if your organization is eligible.

iv.

Utilize self-pay options and inform patients about device manufacturer payment plans or patient assistance programs.

SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES 9 7 Be welcoming and attentive to the health needs of LGBTQ patients.

A.
A.

Be responsive to the health needs of patients who are LGBTQ, including men who have sex with men, women who have sex with women, same-gender-loving, transgender, genderqueer, gender fluid, intersex, asexual and/or any sexual or gender minority.40, 41 B.

Create a welcoming and inclusive environment.

This includes: i.

Requiring ongoing training for front-line, security and clinical staff and volunteers on LGBTQ cultural responsiveness ii.
Prominently displaying nondiscrimination policies and patient bill of rights documents in waiting rooms and examination rooms iii.

Ensuring that medical records and forms are inclusive of LGBTQ patients’ sexual orientation and gender identities C. Be familiar with relevant terminology, such as sex, gender identity, gender-affirming care, gender expression, transgender, transman/transwoman, genderqueer and gender nonconforming.
For additional terms and definitions see Box 3 in the City Health Information document Providing Primary Care to Transgender Adults, available on the New York City Health Department website.

10 SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES D. Discuss contraception and fertility goals with all patients, regardless of sexual orientation and gender identity and expression, while being mindful of patients' identities and lived experiences.
Conversations regarding contraception should ideally serve as an opportunity for further discussions regarding condoms and PrEP as tools to prevent STIs and HIV.

E. For transgender patients, be familiar with clinical standards of a third-party payer coverage for gender-affirming care, including nonmedical changes in gender expression, hormone therapy and surgical treatment.4, 42, 43 i.
Offer gender-affirming services on site or provide referrals to health care settings better equipped to provide these services.

When referring patients to another provider, follow up to ensure timely provision of services.
F. LGBTQ people, especially youth and those with unstable housing, experience disproportionately high rates of sexual coercion compared to the general population.17 Ensure that information on LGBTQ-specific resources for victims of interpersonal and/or relationship violence are made available to patients immediately (e.g., by displaying posters and brochures in waiting areas and patient visit rooms) and by referral.
8 Adopt and implement policies that support patient-centered sexual and reproductive health care.

A.

Hold staff and providers accountable for providing high-quality care that includes same-day initiation of contraception services.7, 8 i.

Model these policies, including confidentiality and patient care policies, on evidence-based sexual and reproductive health care guidelines endorsed by professional organizations and public health entities.

ii.
ii.

Set and adhere to a schedule for reviewing, updating and disseminating policies (e.g., annually).

B.

Conduct ongoing training in i.

Sexual and Reproductive Justice framework ii.

Trauma-informed care iii.

Patient-centered education and counseling methods iv.

Values clarification, with emphasis on identifying and overcoming biases v. Updated clinical guidelines to support evidence-based sexual and reproductive health practices vi.
LGBTQ cultural competency, including important health concerns for gender and sexual minorities vii.

Provision of language access services C. Hold training sessions to reinforce these policies i.

Ensure descriptions of current policies are available in writing (e.g., via employee handbook) and are accessible to all staff.

9 Use data to monitor and improve the quality of patient care.

A.
A.

Build prompting systems (e.g., in electronic health records) to encourage providers to offer sexual and reproductive health screening and service provision.44 B.

Routinely monitor data to ensure patients’ needs are assessed and met (e.g., percentage of patients whose sexual history is taken at least annually, percentage of those screened for STI and HIV, percentage of those offered contraception counseling).
SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES 11 Setting-Specific Contraception and STI/HIV Prevention Care Best Practices The preceding content should serve as foundational recommendations for any provider, while the additional best practices below are specific to the abortion, pre/ postpartum and primary care settings.
• By age 45, three out of 10 women will have had an abortion.45 The abortion care visit presents a timely opportunity to offer interested patients contraception education, counseling and provision.

• Offering contraception care in abortion, primary care and postpartum settings can help reduce unintended pregnancies and help patients space the birth of subsequent children, which affects both maternal and child health.46, 47 Post-Abortion Care 1 Integrate contraceptive counseling into the abortion process.
A.

Provide contraception information as part of the registration and/or intake process.

Inform patients of the range of contraceptive methods that will be available to them immediately after the abortion and the opportunity to obtain more information at the appointment.

B.
B.

At the appointment but prior to the abortion procedure, provide counseling and patient education materials about the full range of FDA-approved contraceptive methods to help patients choose which, if any, is best for them.48, 49 12 SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES 3 Apply up-to-date clinical guidelines for post-abortion contraception care.

A.

Offer the full range of FDA-approved contraceptive methods at the abortion visit via on-site dispensing, insertion or prescription.25 B.
If the patient requests methods not available on-site, provide referrals on the same day as the abortion to sites that offer said methods.

Develop policies to ensure follow-up on referrals.

C. STI screening is generally not required for a patient initiating contraception, including IUDs and implants.

If it is clinically indicated, the provider may conduct STI testing at the abortion visit.

However, do not delay the IUD or implant insertion while awaiting the results of STI testing.
D. If the patient desires, offer implant insertion at the abortion visit, immediately after the procedure.25 E. If the patient desires, offer IUD insertion at the abortion visit, immediately after the procedure.25 i.

No additional prophylactic antibiotics are needed with post-abortion IUD insertion.25 ii.

If you conduct STI testing, you may insert the IUD at the same visit as the abortion and should follow up with the patient as indicated by the STI test results.
2 Use every opportunity to assess and meet the sexual and reproductive health needs of patients accessing abortion services.

A.

Address identified sexual and reproductive health needs at the same visit as the abortion, without delaying until a follow-up visit.

B.

Develop protocols for integrating post-abortion contraception care into the visit(s) to standardize care and support clear patient flow.
SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES 13 Prenatal, Labor and Delivery, and Postpartum Care 1 Integrate contraception, birth spacing and breastfeeding counseling into all pregnancy-related visits.

A.

Provide contraception counseling and patient education materials for the full range of FDA- approved contraceptive methods at i. Prenatal visits ii.

Admission for delivery iii.

Prior to discharge iv.

Follow-up/postpartum visits50-52 B.


As long as patients have no pre-existing conditions that would preclude breastfeeding an infant (e.g., HIV infection, untreated tuberculosis, use of certain medications or illicit drugs),53, 54 recommend that the infant be fed only breast milk for the first six months of life.
Recommend the patient continue breast milk feeding as complementary foods are introduced for an additional six months or longer.53, 55 C. Choosing whether or not to breastfeed may influence patients’ decisions to use certain types of contraception; tailor recommendations accordingly and refer to evidence-based guidelines.

i.
i.

For a visual representation of contraceptive contraindications by health condition (including pregnancy and breastfeeding status) see the CDC MEC charts.50 D. For patients who are breastfeeding, Lactational Amenorrhea Method (LAM) may be an effective form of contraception for up to six months postpartum.
56, 57 Patients should only rely on L AM for contraceptive purposes if they are exclusively (100% of feeding episodes) or nearly exclusively (85-90% of feeding episodes) breastfeeding and have not yet resumed menstruating.

56 E. Counsel patients at prenatal, labor and delivery, and follow-up/postpartum visits about optimal interpregnancy intervals (i.e., birth spacing) to reduce the risk of negative maternal-child health outcomes.

14 SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES i.
Evidence suggests that patients who become pregnant less than 18-24 months after delivering a child are at greater risk of maternal-child health concerns, including pre-term birth, infant low birth weight and small infant size for gestational age.
Patients who become pregnant five years or more after their last delivery are at increased risk of pre-eclampsia.58-60 E. Develop protocols for integrating contraception provision into labor and delivery and postpartum visits to standardize care and support effective patient flow.

4 Apply up-to-date clinical guidelines for labor and delivery and postpartum contraception services.

A.
A.

Offer contraception options to all peripartum patients in accordance with their personal preferences, breastfeeding intentions, medical history and risk factors, and in alignment with contraceptive initiation criteria.25, 50 i.

Additional pelvic exams and Pap smears should not be required for STI and HIV testing or contraception provision.

ii.
ii.

If a patient requests methods not available during hospitalization, assist the patient in making an appointment prior to discharge with another clinician who can provide the requested method.

The patient should be provided with contact information and the date and time of the appointment.

B.

Offer contraceptive methods during the maternity stay via on-site dispensing or prescription.
Assess appropriateness of postpartum initiation based on patients’ breastfeeding intentions, medical history and risk factors, and other criteria.50 2 Ensure the confidentiality of postpartum contraception care.

A.

Ensure that patients and providers have time alone to speak.

B.

Give patients the opportunity to have their chosen contraceptive method provided/inserted privately without others present.
3 Use every opportunity to assess and meet contraception needs of patients who are pregnant or recently gave birth.

A.

Take a brief sexual history at the prenatal and postpartum visits to identify needs for education, contraception, STI and HIV screening/testing or other services.

B.
B.

Educate pregnant patients on the need for continued use of condoms to prevent transmission of HIV and other STIs, particularly if the patient is at elevated risk of exposure (e.g., has an HIV- positive partner, uses intravenous drugs).61 i.
Offer routine HIV testing to all prenatal care patients; re-screen for HIV during the third trimester of pregnancy if the patient is determined to be at ongoing risk of infection.7, 8, 29 C. Routinely assess patients for reproductive coercion and intimate partner violence at prenatal, labor and delivery, and postpartum visits, and provide prompt treatment and referrals.62 D. Address identified sexual and reproductive health needs at the prenatal, labor and delivery, and postpartum visits, without delaying until a follow-up visit.
SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES 15 ii.

For patients who are 21 to 42 days postpartum and do not have additional risk factors for VTE, the benefits of CHC use generally outweigh the risks.

iii.

No restriction on postpartum CHC applies to patients more than 42 days after delivery; however, other risk factors or contraindications for CHCs must still be considered.

E. For breastfeeding patients, the following CDC MEC guidelines on CHC use apply:50 i.
Patients who are 21 to 29 days postpartum should generally not use CHCs, whether or not they have additional risk factors for VTE.

ii.

Patients who are 30 to 42 days postpartum and have additional risk factors for VTE should generally not use CHCs.

iii.

For patients who are 30 to 42 days postpartum and do not have additional risk factors for VTE, the benefits of CHC use generally outweigh the risks.

iv.
iv.

For patients who are more than 42 days postpartum, the benefits of CHC use generally outweigh the risks; however, other risk factors or contraindications for CHCs must still be considered.

F. According to the CDC MEC guidelines for the post-partum period, the benefits of progestin- only contraceptive methods (e.g.

progestin-only pills, the shot, the implant and the hormonal IUD) as well as the non-hormonal IUD, generally outweigh the risks.50 i.
These methods are usually safe to use for patients who are breastfeeding, and may be offered before discharge from delivery care, provided other patient risk factors or contraindications are considered.

G. Encourage postpartum patients to use condoms to reduce the risk of unintended pregnancy and STIs, including HIV.

Condoms may be initiated any time postpartum.


i. IUDs and implants may be inserted immediately after vaginal or Cesarean delivery if the patient has been screened for contraindications during the prenatal period and has no additional risk factors.50 • Insertion of an IUD is safe within 10 minutes after delivery of the placenta.
Waiting longer than 10 minutes is associated with a higher expulsion rate.50, 63 There is also a higher risk of IUD expulsion among patients who have an IUD inserted within 28 days postpartum compared to those who opt for delayed insertion.50 • Patients who experience peripartum infection should wait at least three months postpartum before having an IUD placed.23, 64 C. Use of combined hormonal contraceptives (CHCs), such as pills, the patch and the ring, sooner than 21 days postpartum is considered an unacceptable health risk due to the elevated risk of venous thromboembolism (VTE).
i.

This recommendation is made for all patients, regardless of breastfeeding intentions and/or presence of additional risk factors for VTE.50 D. For non-breastfeeding patients, the following H. Use of the cervical cap or diaphragm should be CDC MEC guidelines on CHC use apply:50 delayed until six weeks postpartum.

i.

Patients who are 21 to 42 days postpartum I.


Use the postpartum visit to reevaluate patients’ and have additional risk factors for VTE should generally not use CHCs, as the risks outweigh possible benefits.

satisfaction and consistency of use of the chosen method.

If they are not satisfied, offer another contraceptive method.

16 SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES Primary Care 1 Integrate preconception care, pregnancy intention and contraceptive counseling into primary care visits.
A.

At a minimum, initiate conversation about pregnancy intention, preconception care and contraception at the annual visit and whenever new diagnoses or medications may be relevant to pregnancy risks or contraceptive method contraindications.7, 8, 65, 66 i.
Consider using the “One Key Question®” approach: • Pose the question: “Would you like to become pregnant in the next year?” – For patients who answer “yes,” offer pre- conception counseling and screenings to ensure that they are in optimal health for a pregnancy.

– For patients who answer “no,” counsel on the full range of contraception options to ensure that the method they use is optimal for their circumstances.
– Patients who are ambivalent or unsure of their pregnancy intentions comprise a substantial portion of the population; offer these patients a combination of both services.

B.

Discuss the relationship between patients’ sexual and reproductive health goals, overall health and well-being and contraception choices (e.g., medical conditions that affect pregnancy risk, potential drug interactions, contraceptive contraindications, side effects, etc.).
C. During primary care visits, when taking a medication history, include an inquiry about contraception and whether the patient is satisfied with their current contraceptive method.

i.

If the patient is unhappy with their current contraceptive method, assess method concerns and recommend alternatives.

D. For adolescents, primary care visits should (at a minimum) include:5, 66, 67 i.

Time alone with the provider ii.


Discussion about sexual activity, including STI and HIV prevention counseling as appropriate iii.
Contraception and pregnancy intention counseling and services SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES 17 Tools and Resources ADOLESCENT HEALTH CARE CONTRACEPTION CARE AND PROVISION Resource Type Title Reference General Resource Sexual and Reproductive Health: Information for Providers New York City Health Department General Resource One Key Question®: Preventive Reproductive Health is Part of High Quality Primary Care.

Bellanca, H.K., Hunter, M.S.

Contraception 2013;88:3-6.


Best Practices, General Resource A Guide to Taking a Sexual History New York City Health Department Best Practices U. S. Medical Eligibility Criteria for Contraceptive Use, 2010 CDC Best Practices U.S.

Selected Practice Recommendations for Contraceptive Use, 2013: Adapted from the World Health Organization selected practice recommen- dations for contraceptive use, 2nd ed.
Best Practices Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs Best Practices Update: Providing Quality Family Planning Services: Recommendations from CDC and the U.S. Office of Population Affairs, 2015 CDC MMWR Recomm Rep 2013; w62:1-60 Gavin, L., Moskosky, S., Carter, M., et al.

Centers for Disease Control and Prevention.

MMWR Recomm Rep 2014;63:1-54.

Gavin, L., Pazol, K. Centers for Disease Control and Prevention.
MMwR Morb Mortal Wkly Rep 2016;65:231-4.

STI AND HIV PREVENTION AND TREATMENT Resource Type Title Reference Training HIV, HCV and STD Clinical Education Initiative Best Practices Sexually Transmitted Diseases Treatment Guidelines, 2015 The New York State Department of Health AIDS Clinical Education Initiative (CEI) Workowski, K.A., Bolan, G.A.

MMWR Recomm Rep 2015;64:1- 137.

Errata: Vol.

64, No.

RR-3; August 28, 2015 / 64(33);924.
Best Practices Pre-exposure Prophylaxis for the Prevention of HIV Infection in the United States–2014: A Clinical Practice Guideline CDC 18 SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES Resource Type Title Reference Workshop Guide Teens In NYC: Getting Sexual Health Services New York City Health Workshop Facilitation Guide Department Toolkit AHWG's Provider Toolkit Series Best Practices, General Resource Best Practices, General Resource Clinical Care Guidelines and Resources GAPS-The Guidelines for Adolescent Preventive Services Adolescent Health Working Group (AHWG) Society for Adolescent Health and Medicine American Academy of Family Physicians PATIENT-CENTERED CARE AND THE SEXUAL AND REPRODUCTIVE JUSTICE FRAMEWORK Resource Type Title General Resource What is Reproductive Justice?
Reference Asian Communities for Reproductive Justice General Resource Forward Together: Resources Forward Together General Resource Trauma-Informed Approach and Trauma- Specific Interventions Substance Abuse and Mental Health Services Administration General Resource A 2020 Vision of Patient-Centered Primary Care Audet, A.M. J Gen Intern Med Davis, K., Schoenbaum, S.C., 2005;20:953-7.
University of California, San Francisco Office of Diversity and Outreach General Resource Unconscious Bias Training Trust Black Women: Training Trust Black Women CONTRACEPTION CARE AND PROVISION Resource Type Title Reference Department General Resource for Providers Sexual and Reproductive Health: Information New York City Health General Resource One Key Question®: Preventive Reproductive Health is Part of High Quality Primary Care.

Bellanca, H.K., Hunter, M.S.

Contraception 2013;88:3-6.


Best Practices, General Resource A Guide to Taking a Sexual History New York City Health Department Best Practices Use, 2010 U. S. Medical Eligibility Criteria for Contraceptive CDC Best Practices U.S.

Selected Practice Recommendations for Contraceptive Use, 2013: Adapted from the World CDC MMWR Recomm Rep 2013; Health Organization selected practice recommen- w62:1-60 dations for contraceptive use, 2nd ed.
Best Practices Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs Best Practices Update: Providing Quality Family Planning Services: Recommendations from CDC and the U.S. Office of Population Affairs, 2015 Gavin, L., Moskosky, S., Carter, M., et al.

Centers for Disease Control and Prevention.

MMWR Recomm Rep 2014;63:1-54.

Gavin, L., Pazol, K. Centers for Disease Control and Prevention.

MMwR Morb Mortal Wkly Rep 2016;65:231-4.


STI AND HIV PREVENTION AND TREATMENT Resource Type Title Reference Training HIV, HCV and STD Clinical Education Initiative Best Practices Sexually Transmitted Diseases Treatment Guidelines, 2015 Best Practices HIV Infection in the United States–2014: A Clinical CDC Pre-exposure Prophylaxis for the Prevention of Practice Guideline The New York State Department of Health AIDS Clinical Education Initiative (CEI) Workowski, K.A., Bolan, G.A.
MMWR Recomm Rep 2015;64:1- 137.

Errata: Vol.

64, No.

RR-3; August 28, 2015 / 64(33);924.
ADOLESCENT HEALTH CARE Resource Type Title Reference Workshop Guide Teens In NYC: Getting Sexual Health Services Workshop Facilitation Guide New York City Health Department Toolkit AHWG's Provider Toolkit Series Best Practices, General Resource Clinical Care Guidelines and Resources Best Practices, General Resource GAPS-The Guidelines for Adolescent Preventive Services Adolescent Health Working Group (AHWG) Society for Adolescent Health and Medicine American Academy of Family Physicians PATIENT-CENTERED CARE AND THE SEXUAL AND REPRODUCTIVE JUSTICE FRAMEWORK Resource Type Title General Resource What is Reproductive Justice?
Reference Asian Communities for Reproductive Justice General Resource Forward Together: Resources Forward Together General Resource Trauma-Informed Approach and Trauma- Specific Interventions Substance Abuse and Mental Health Services Administration General Resource A 2020 Vision of Patient-Centered Primary Care General Resource Unconscious Bias Davis, K., Schoenbaum, S.C., Audet, A.M. J Gen Intern Med 2005;20:953-7.
University of California, San Francisco Office of Diversity and Outreach Training Trust Black Women: Training Trust Black Women SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES 19 LGBTQ HEALTH CARE HEALTH INSURANCE ACCESS Resource Type Title Reference Resource Type Title General Resource Lesbian, Gay, Bisexual and Transgender Health CDC General Resource Health Insurance Programs Reference New York State Department of Health Best Practices Program Assistance Letter: Approved changes for CY 2016 UDS Reporting.
A.

Sexual Orientation and Gender Identity – Tables 3A, 3B Health Resources and Services Administration Best Practices, General Resource Taking Routine Histories of Sexual Health: A System-Wide Approach for Health Centers National LGBT Health Education Center and the National Association of Community Health Centers.

November 2015.
General Resource New York State Medicaid Family Planning Services New York State Department Frequently Asked Questions, May 2015 of Health General Resource Family Planning Benefit Program (FPBP) Update New York State Department of Health General Resource Family Planning Extension Program NYC Health Insurance Link Best Practices, General Resource Best Practices, General Resource Best Practices, General Resource Best Practices, General Resource Lesbian and Bisexual Health Fact Sheet Office on Women’s Health Providing Comprehensive Health Care to Men Who Have Sex With Men (MSM) New York City Health Department.
City Health Information 2014;33.

Center of Excellence for Transgender Health – Learning Center Audience: Health Care Providers University of California San Francisco Providing Primary Care to Transgender Adults Training Webinars Sponsored by the National LGBT Health Education Center New York City Health Department.

City Health Information 2014;34.


National LGBT Health Education Center: A Program of The Fenway Institute INTIMATE PARTNER VIOLENCE AND REPRODUCTIVE COERCION Resource Type Title Reference General Resource Liletta Patient Savings Program Actavis Pharma Inc. Best Practices, Toolkit Addressing Intimate Partner Violence, Reproductive and Sexual Coercion: A Guide for Obstetric, Gynecologic and Reproductive Health Care Settings Chamberlain, L., Levenson, R. Futures Without Violence, 2012, 2nd ed.
San Francisco, CA.

General Resource Reimbursement Intrauterine Devices and Implants: A Guide to Armstrong, E., Gandal-Powers, M., Levin, S., Kelinson, A.K., Luchowski, A., Thompson, K. Toolkit Exposing Reproductive Coercion: A Toolkit for Awareness Raising, Assessment, and Intervention Cappelletti, M., Gatimu, J., Shaw, G. (2014).

FWHC, NCADV.
FWHC, NCADV.

Webinar Slides, General Resource Redefining Safety Planning in the Context of Reproductive Coercion Futures Without Violence Journal Article Guarding Against Coercion While Ensuring Access: A Delicate Balance Gold, R.B.

Guttmacher Policy Review 2014;17.

Journal Article Celebration Meets Caution: LARC's Boons, Potential Busts, and the Benefits of a Reproductive Justice Approach Higgins, J.A.

Contraception 2014;89:237-41.
20 SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES FINANCIAL ASSISTANCE AND DEVICE REIMBURSEMENT Resource Type Title General Resource 340 B Drug Pricing Program General Resource Mirena ARCH Patient Assistance Program for Skyla and Bayer Healthcare General Resource Skyla: Specialty Pharmacy Program Reference U.S. Department of Health and Human Services Pharmaceuticals Inc. Bayer Healthcare Pharmaceuticals Inc. LGBTQ HEALTH CARE HEALTH INSURANCE ACCESS Resource Type Title Reference Resource Type Title General Resource Lesbian, Gay, Bisexual and Transgender Health CDC General Resource Health Insurance Programs Reference New York State Department of Health Best Practices Program Assistance Letter: Approved changes for CY 2016 UDS Reporting.
A.

Sexual Orientation and Gender Identity – Tables 3A, 3B Health Resources and Services Administration Best Practices, General Resource Taking Routine Histories of Sexual Health: A System-Wide Approach for Health Centers National LGBT Health Education Center and the National Association of Community Health Centers.

November 2015.
General Resource New York State Medicaid Family Planning Services Frequently Asked Questions, May 2015 New York State Department of Health General Resource Family Planning Benefit Program (FPBP) Update New York State Department of Health General Resource Family Planning Extension Program NYC Health Insurance Link FINANCIAL ASSISTANCE AND DEVICE REIMBURSEMENT Resource Type Title General Resource 340 B Drug Pricing Program Reference U.S. Department of Health and Human Services General Resource ARCH Patient Assistance Program for Skyla and Mirena Bayer Healthcare Pharmaceuticals Inc. General Resource Skyla: Specialty Pharmacy Program Bayer Healthcare Pharmaceuticals Inc. Resource Type Title Reference General Resource Liletta Patient Savings Program Actavis Pharma Inc. Best Practices, Toolkit Addressing Intimate Partner Violence, Reproductive Chamberlain, L., Levenson, R. and Sexual Coercion: A Guide for Obstetric, Futures Without Violence, 2012, Gynecologic and Reproductive Health Care Settings 2nd ed.
San Francisco, CA.

General Resource Intrauterine Devices and Implants: A Guide to Reimbursement Armstrong, E., Gandal-Powers, M., Levin, S., Kelinson, A.K., Luchowski, A., Thompson, K. Best Practices, General Resource Best Practices, General Resource Best Practices, General Resource Best Practices, General Resource Lesbian and Bisexual Health Fact Sheet Office on Women’s Health Providing Comprehensive Health Care to Men Who New York City Health Department.
Have Sex With Men (MSM) City Health Information 2014;33.

Center of Excellence for Transgender Health – University of California Learning Center Audience: Health Care Providers San Francisco Providing Primary Care to Transgender Adults Training Education Center Webinars Sponsored by the National LGBT Health New York City Health Department.

City Health Information 2014;34.


National LGBT Health Education Center: A Program of The Fenway Institute INTIMATE PARTNER VIOLENCE AND REPRODUCTIVE COERCION Toolkit Exposing Reproductive Coercion: A Toolkit for Cappelletti, M., Gatimu, J., Shaw, Awareness Raising, Assessment, and Intervention G. (2014).

FWHC, NCADV.
FWHC, NCADV.

Webinar Slides, General Resource Redefining Safety Planning in the Context of Reproductive Coercion Futures Without Violence Journal Article A Delicate Balance Guarding Against Coercion While Ensuring Access: Gold, R.B.

Guttmacher Policy Journal Article Potential Busts, and the Benefits of a Reproductive Celebration Meets Caution: LARC's Boons, Justice Approach Review 2014;17.

Higgins, J.A.

Contraception 2014;89:237-41.

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24 24 SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES SEXUAL AND REPRODUCTIVE HEALTH CARE BEST PRACTICES 04/18