Statewide Contraceptive Access Initiatives:
Updated Environmental Scan Report
June 2024
Nikita Malcolm, MPH
Jessica DanauxAshi Parikh, MPH
Julia Wilson, MSW
Sara Redd, PhD, MSPH
Whitney Rice, DrPH
Jamie Hart, PhD

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TABLE OF CONTENTS
ABSTRACT.................................................................................................................................. 1
INTRODUCTION ......................................................................................................................... 1
METHODS .................................................................................................................................. 2
SUMMARY OF FINDINGS ............................................................................................................ 3
Description of Search Results .............................................................................................................. 3
Overview of Statewide Contraceptive Access Initiatives ....................................................................... 4
Implementation of Statewide Contraceptive Access Initiatives............................................................. 5
Evaluation of Statewide Contraceptive Access Initiatives ..................................................................... 6
Sustainability .................................................................................................................................... 13
Applying Equity-and Justice-Focused Frameworks in Statewide Contraceptive Access Initiatives ........ 15

RESEARCH GAPS AND IMPLICATIONS ....................................................................................... 16
CONCLUSION ........................................................................................................................... 18
APPENDIX A: SEARCH TERMS AND INCLUSION/EXCLUSION CRITERIA ........................................ 19
APPENDIX B: OVERVIEW OF STATEWIDE CONTRACEPTIVE ACCESS INITIATIVES ......................... 20
APPENDIX C: REFERENCES ........................................................................................................ 23ii

ABSTRACT: UPDATED ENVIRONMENTAL SCAN REPORTStatewide Contraceptive Access Initiatives (SCAI) expand access to contraception by bringing together key
stakeholders and partner organizations committed to mobilizing interest in expanding access tocontraceptive services, increasing health center capacity to provide services, and removing structuralbarriers to contraceptive access, such as cost. This report presents an overview of the existing evidence inthe published and grey literature related to the implementation and evaluation of SCAI—as well as theinitiatives’ effects on expanding contraceptive access; identifies gaps in the available evidence; and makes
recommendations for future research. Sixty-one relevant resources were identified in the scan, describing
implementation approaches and evaluation findings across 30 states and/or territories that have
implemented, or are currently implementing, contraceptive access initiatives. The environmental scanfindings demonstrate that SCAI consist of similar implementation approaches, including clinician andsupport staff training and technical assistance; funding for the provision of low/no-cost contraceptive
services and supplies; public awareness campaigns; and public policy analysis and championing. The
available evidence describes effects on contraceptive use, service utilization, and pregnancy-related
outcomes. Research gaps remain in understanding the impact of SCAI in reducing inequities incontraceptive access and fostering sustainability.

INTRODUCTION
Statewide Contraceptive Access Initiatives (SCAI) expand access to contraception by bringing together key
partners committed to advancing access, increasing health center capacity to provide services, andremoving structural barriers to contraceptive access, such as cost. Since the early 2000s, more than
SCAI have been implemented in the U.S., a creating a key opportunity for ongoing and future efforts to be
shaped by previous project activities, challenges, and successes.

SCAI Definition
SCAI are projects implemented across all or multiple regions of a state that involve a coalition of key
stakeholders from public, private, and non-profit sectors who undertake coordinated efforts to increase
access to contraception. Efforts focus on:• Mobilizing interest in expanding access to contraception• Providing contraceptive products at no or low cost
• Providing training and capacity building• Removing other structural barriers to enhanced contraceptive access

SCAI share the intent of expanding access to contraceptive services and supplies with a variety of expressed
goals, including reducing unintended, unplanned, and/or teen pregnancy and increasing equitable access toservices to support contraceptive choice and decision-making.1 There is growing evidence that SCAI canadvance the provision of person-centered care, expand contraceptive access, and improve healthoutcomes.2–4
As some of the legacy SCAI end and a new generation of SCAI emerge, there is a critical need to expand thepotential of these initiatives with an eye toward advancing Sexual and Reproductive Health Equity (SRHE)
across all phases of project implementation and evaluation. In 2023, the Coalition to Expand Contraceptive
Access (CECA), in partnership with the Center for Reproductive Health Research in the Southeast (RISE) ata This includes the 27 states and/or territories that participated in a multi-state contraceptive access learning community

coordinated by the Association of State and Territorial Health Officials (ASTHO), as well as additional SCAI that are documented in
the literature that did not participate in the ASTHO project.

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Emory University, launched a collaborative effort to document and share lessons learned across SCAI, andidentify opportunities to advance implementation. To inform this effort, the team conducted anenvironmental scan to synthesize existing evidence describing SCAI implementation and evaluation
approaches, outcomes, and lessons learned, and update the findings of a previous environmental scan on
SCAI that CECA conducted in 2021. The team sought to identify evidence to address the following key
research questions:

Key Research Questions
1. What SCAI have been initiated since 2005, and why were these initiatives undertaken?
What is the current status of these SCAI (e.g., completed, in-progress)?
How have the SCAI evolved since their inception?
2. What are the implementation approaches for SCAI, and what lessons have been learned?
3. What are the evaluation approaches for SCAI, and what lessons have been learned?
a. At what phase of data collection/analysis are the various SCAI?
b. What outcomes are being assessed among SCAI, and how are various outcomes measured?
4. What findings have been published on the impact of SCAI related to:
Outcomes for health centers and healthcare providers?
Outcomes for clients and potential clients (e.g., contraception use, client satisfaction)?
Health and social outcomes?
Public policy outcomes?
5. When the current SCAI conclude, what will we be positioned to understand about their impact? Whatquestions will remain?

METHODSThis report combines the findings of two distinct environmental scan efforts with similar methodologies –an original environmental scan of published materials related to SCAI conducted by CECA in 2021, and an
updated environmental scan conducted by RISE in 2024. Both scans consisted of a review of descriptive andexperimental peer-reviewed publications and grey literature (e.g., commentaries, white papers, conference
abstracts, blog posts, webpages) that addressed implementation, evaluation, and outcomes of SCAI
implemented in the U.S. Evidence on completed SCAI projects and projects in progress were eligible forinclusion in the scans—including projects specifically focused on contraceptive access, such as long-acting
reversible contraception (LARC) access projects—and all method approaches.
The teams searched PubMed, Google Scholar, and Google Search to identify relevant articles published fromJanuary 2005 through January 2024. Search terms included statewide initiative-related terms (e.g.,“contraceptive access”; “LARC Access”; “statewide”) and terms to identify implementation and evaluation(e.g., “implementation”; “evaluation”; “assessment”; “outcomes”). A complete list of search terms can befound in Appendix A. The scans also considered unpublished information available through a collaborative
project undertaken by CECA and the Association of State and Territorial Health Officials (ASTHO) in 2020 to
explore the feasibility of seeking a Centers for Disease Control and Prevention (CDC) Community Guide
recommendation on SCAI, which resulted in the publication of a special issue in the American Journal of
Public Health entitled “Reshaping Contraceptive Access Efforts by Centering Equity, Justice, and Autonomy.”

2The environmental scans excluded projects that focused solely on increasing access to immediate
postpartum (IPP) LARC, with an exception made for states that participated in an ASTHO Learning
Community that initially focused on increasing access to IPP LARC, and later expanded to focus on access toall contraceptive methods more broadly. The rationale for non-inclusion was that implementation of the
IPP LARC initiatives relied almost exclusively on modifying hospital practices and state Medicaid
reimbursement policies, rather than the broader set of activities typically undertaken by SCAI. Teenpregnancy prevention projects conducted collaboratively by the CDC, Office of Adolescent Health, andOffice of Population Affairs (OPA) were also not included, as these projects were multi-component,
community-wide initiatives that were heavily focused on implementation of evidence-based curriculum
and youth development approaches, and contraceptive access was not a primary focus.5
Local contraceptive access projects, such as those undertaken in Rochester, NY6 and Tulsa, OK7, were notincluded in this scan, as their focus was on a local area rather than statewide, and in the case of theRochester project, focused only on teens. Some information from the HER Salt Lake Initiative is included, as
this work was formative for the Utah statewide initiative, Family Planning Elevated (FPE) Program.4

SUMMARY OF FINDINGS
Description of Search Results
The team identified 61 resources (e.g., journal articles, reports, websites, whitepapers) describing theimplementation, evaluation, outcomes, and the impact of SCAI that have been implemented in the U.S.,
along with evidence from a related multi-state learning community, coordinated by ASTHO. SCAI includedin this scan are listed in Table 1. Additional details for each SCAI are provided in Appendix B.
Table 1. Overview of SCAI Included in the Environmental Scan
State

Initiative Name

Lead Organization

StatusColorado

Colorado Family Planning Initiative(CFPI)

Colorado Department of Public
Health and Environment

Complete; 2008-2014

State of Delaware and Upstream USA

Complete; 2015-2020

AllianceChicago

Ongoing; 2021-2025

DelawareIllinois

Delaware Contraceptive AccessNow (DelCAN)
Illinois Contraceptive Access Now(ICAN!)

Indiana

PATH4YOU

Indiana University School of Medicine

Ongoing; 2020-

Iowa

Iowa Initiative to Reduce
Unintended Pregnancies

The Iowa Initiative

Complete; 2007-2013

Massachusetts

Massachusetts Initiative to
Improve Contraception Services

Massachusetts Executive Office of
Health and Human Services

Complete; 2018-2023

Missouri

The Right Time (TRT)

Missouri Family Health Council

Ongoing; 2019-2028

Nebraska

Nebraska Sexual and Reproductive
Health Initiative

Nebraska Family Planning

Ongoing; 2023-

South Carolina

Choose Well Initiative

New Morning

Ongoing; 2017-

Utah

Family Planning Elevated (FPE)

University of Utah Department of
Obstetrics & Gynecology

Complete; 2019-2022

For the purposes of the CECA/RISE effort, states that participated in the ASTHO Learning Communities were considered
to fit the definition of “statewide contraceptive access initiatives” and also included in this scan.8 Those states/territories
included: Alabama; Alaska; California; Colorado; Commonwealth of the Northern Mariana Islands; Connecticut;
Delaware; Florida; Georgia; Illinois; Indiana; Iowa; Kentucky; Louisiana; Maryland; Massachusetts; Mississippi; Montana;
New Mexico; New York; North Carolina; Oklahoma; South Carolina; Texas; Washington; West Virginia; and Wyoming.

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Overview of Statewide Contraceptive Access Initiatives
Origination and Evolution of SCAI
Many of the early contraceptive access projects were modeled after the Contraceptive CHOICE study(CHOICE), a regional contraceptive access initiative implemented in 2006. CHOICE enrolled over 9,000
women in the St. Louis, Missouri area in a research project to promote and provide the most effective
reversible methods of contraception, including intrauterine devices (IUD) and contraceptive implants. While
all contraceptive methods were available at no cost, information about contraceptive methods waspresented in a “tiered” approach, from most to least effective, meaning that LARC methods were presented
first. The study found that when both knowledge and cost barriers were eliminated, 75% of participantschose LARC methods, and LARC continuation rates at 12 and 24 months were 86% and 77%, respectively.9
Beyond method choice and continuation rates, the study also found substantial reductions in teen
pregnancy, birth, and abortion.10
Based on the success of the 2006 CHOICE Project in St. Louis, statewide projects that heavily focused on
uptake of LARC were privately funded in Iowa and Colorado.
The Iowa Initiative to Reduce Unintended Pregnancies was a five-year project that began in 2007 andemployed a multi-component approach that included family planning providers, an advocacy organization,
and a university research center. The aims of the project were to reduce unintended pregnancies and thenumber of abortions among adult women ages 18-30 years by increasing access to family planning services,
the use of LARC methods, the number of low-income individuals who accessed family planning services,and public funding for family planning. In addition, the project sought to improve the political climate
regarding family planning through a statewide marketing campaign and outreach to a number ofprofessional, governmental, and business representatives.11,12
The Colorado Department of Public Health and Environment began receiving private funding in 2008 tolaunch the Colorado Family Planning Initiative (CFPI), which supported an expansion of the state’s Title X
Family Planning Program, including training, operational support, and low/no-cost LARC to low-income
women statewide. Enhanced training and technical assistance were provided to staff to enable them toincrease utilization of these methods. The expressed goal of the CFPI was to “reduce unintended pregnancy
by increasing access to family planning services for low-income women and men, improving the capacity ofhealthcare settings to provide family planning services, and increasing coverage of all contraceptive
methods by removing cost barriers for the most effective methods: long-acting reversible contraception.”13
In response to the documented impact of these initiatives, state and funder interest prompted theimplementation of several contraceptive access initiatives focused on addressing barriers specific to LARC
access, including cost and logistical barriers (e.g., need for provider training on insertion and removal, lackof availability of devices in clinics and hospitals, high costs of LARC devices that made them unattainable formany people). Many of these early initiatives were generally categorized as 1) LARC “first”, referring toprojects that “promoted” the uptake of LARC above other contraceptive methods, particularly among“high-risk” populations, framing LARC as a “first-line” contraceptive that should be offered to all women14,
or 2) LARC “access”, referring to projects focused on reducing or eliminating barriers to LARC access, butthat do not necessarily employ counseling techniques that promote uptake of LARC above other methods.
(for text box 14,15
Concern grew within the reproductive health, rights, and justice community that LARC promotion efforts wereactually or potentially coercive, undermined reproductive autonomy, were not patient-centered, and were in
conflict with Reproductive Justice principles. 14,15

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Likely based on these concerns within the reproductive health, rights, and justice community, initiatives
shifted, over time, to approaches that included offering the full range of contraceptive options, most usinga shared decision-making approach that centers individual preferences and priorities.16 The majority of SCAI
implemented in the past ten years focus on access to all contraceptive methods and employ strategies toensure that all methods are available for individuals to choose the method that will work best for them.

Implementation of Statewide Contraceptive Access Initiatives
Common Intervention Components
In 2020, CECA and ASTHO, along with seven SCAI partners identified eight multilevel core intervention
components commonly implemented across SCAI.1 These core intervention components were confirmed ina series of listening sessions CECA convened in 2023 with SCAI leaders and are listed in Table 2. The
following sections describe the implementation of these components across various SCAI, based onevidence identified in the scan.
Table 2. Core Intervention Components Implemented Across SCAI
As published in the American Journal of Public Health

Healthcare Organization

Healthcare Provider

Level

Intervention
Component

Description

Training/Continuing
education

Training for clinicians, support staff, and administrative staff through various
modalities (e.g., small-group in-person training, one-on-one proctoring, virtual
webinar series) on topics including family planning 101; medical management ofcontraception; hands-on clinical skills (e.g., LARC insertion and removal); billing,coding, and reimbursement; and preventing coercion and bias.

Ongoing technicalassistance

Providing ongoing, targeted technical assistance to clinicians, support staff, andadministrative staff delivered via various modalities (e.g., coaching calls, training
specialists in-clinic) on topics including hands-on clinical skills; purchasing, stocking,and billing for contraceptives; patient education materials; contraceptive accesspolicies/procedures; contraceptive workflow; data collection and reporting.

Provision of low- or
no-costcontraception

Direct funding and/or stocking for participating health centers across delivery settings(e.g., Title X clinics, Federally Qualified Health Centers (FQHCs), school-based healthcenters (SBHCs), hospitals for immediate post-partum contraception, abortion
providers for immediate post-abortion contraceptionb) to offer FDA-approved
contraceptive methods and services to eligible individuals at low/no-cost without perclient caps on use of contraceptive services and devices.

Grants forequipment/supplies

Direct funding to participating health centers to purchase contraceptive supplies andequipment, other clinic supplies (e.g., exam tables, technology for patient education),and personnel costs.

Quality
improvement, data,
monitoring, andevaluation

Conducting continuous quality improvement and providing feedback to quickly
identify implementation barriers and potential strategies to address barriers.
Measuring aggregate, deidentified utilization of various contraceptives, provision ofcontraception services or person-centered counseling, and knowledge, skills,
attitudes, or beliefs about contraception among providers.

b Two of the seven contraceptive access initiatives that participated in CECA and ASTHO’s virtual meeting series in2020 included post-abortion contraception access in their projects.
5Public Policy

Community

Level

Intervention
Component

Description

Public awarenesscampaign

Digital media and marketing campaigns to increase awareness about the availability of
reproductive health services and provide information and resources on reproductive
health topics.

Stakeholder
engagement

Engaging multi-stakeholder partnerships with public and private entities for effective
implementation.

Legislation or otherpublic policychangeChampioning enactment and implementation of legislation and public policy tosupport contraceptive access, including overall public and private insurance coveragefor contraception, such as LARC coverage and reimbursement and multiple months ofdispensing; expanded ability of providers (e.g., pharmacists, advanced practiceclinicians) to prescribe and dispense contraception; ensured payment parity forproviders; and over-the-counter contraception without a prescription.

Training/Continuing Education
Most SCAI include training and continuing education for healthcare providers and staff, including clinic
administrative and community organization staff (e.g., medical assistants, front desk staff, social workers,
community health workers, Title V home visitors), at clinical and community partner sites as a part ofproject implementation.
Training occurs across several levels of health center staff on a range of topics. For example, in Delaware,training was provided to clinicians and support staff, including medical assistants, front desk staff,
accounting and billing staff, and other administrative staff, to increase clinical, counseling, andadministrative capacity for providing the full range of contraceptive methods.2 In South Carolina, forexample, support was also provided to nursing schools to incorporate hands-on reproductive health andcontraceptive education and training to family nurse practitioner students.17,18
Clinician and staff trainings use various modalities (e.g., small-group in-person training, one-on-one
proctoring, virtual webinar series, conference training sessions, train-the-trainer approaches) andencompass a range of topics, including LARC insertion and removal; medical management of contraception
aimed at increasing awareness of CDC’s evidence-based contraceptive guidance (US MEC and US SPR),
billing, coding, and reimbursement; person-centered contraceptive counseling and education; and the roleof bias and coercion in reproductive healthcare.19 For example, in Utah, the full patient care team atpartnering clinics, from administrators to providers, receive tailored education and training on a variety of
topics, including person-centered contraceptive counseling, LARC placement and removal, fertility
awareness-based methods, clinic workflow, billing and coding, and other areas of need jointly identified byclinics and the research team. Clinic staff at all levels, including front desk staff and medical assistants, wereinvolved in education and training to support capacity for contraceptive provision throughout the entire
clinic.20 (for text box 20)

Utah’s Family Planning Elevated: Training Sustainability Strategies
Family Planning Elevated Contraceptive Access Program (FPE CAP) members are asked to identify clinic
champions at the provider, medical assistant, and administrative levels to support the project and toincrease the likelihood of sustainability after the program ends. Clinic providers who receive IUD and
implant training also receive onsite proctoring and mentorship, clinical assistance with complex cases,
and additional specific training, such as IPP insertions. Providers also have access to an on-call nurse
practitioner who specializes in family planning care to support and troubleshoot any issues. 20
1Ongoing Technical AssistanceTechnical assistance involves targeted, one-on-one site-specific or person-specific assistance provided toassist clinicians, support staff, administrative staff, and other clinical and community partner staff on a
range of person or site-specific topics. SCAI often provide technical assistance to partnering health centersaround billing and coding, updating or creating clinical protocols, stocking of contraceptive products,
making electronic health record modifications, and collecting and analyzing data. For example, for The Right
Time initiative in Missouri, family planning clinical consultants supported health centers by modifying clinic
workflows to allow more time during patient visits to deliver same-day services, which contributed to an
overall increase in same-day access to contraception.21 ICAN! in Illinois’ technical assistance focused on
supporting FQHC staff to build financial sustainability through developing clinic workflows that makes it
easier to stock same-day contraceptive supplies, determining coverage eligibility, and maximizing
reimbursement through accurate billing and coding practices.22
Provision of Low- or No-Cost Contraception
Most SCAI included in this scan provide(d) low/no-cost contraceptive products, through a combination of
public and private funding. The ability to provide contraceptive methods at no cost to all patients isdependent on private funding, while leveraging public programs, such as Title X, enables SCAI to offer lowcost contraception. For example, the private funder of the CFPI in Colorado provided funding to support theprovision of LARC, and DelCAN in Delaware received funding for the purchase of LARC devices from the
Delaware Division of Public Health.2,23 In general, SCAI leverage multiple reimbursement and financing
sources, including Medicaid, private insurance, Title X, the 340B Drug Pricing Program, Temporary
Assistance for Needy Families (TANF), and donor funding, to facilitate access to low/no-cost
contraceptives.19
Grants for Equipment and Supplies
Direct funding to support the funding of contraceptive supplies, clinical infrastructure, personnel costs, andadministrative overhead is often a core intervention component of SCAI. Both the Colorado and South
Carolina initiatives provided direct funding for purchasing equipment and hiring staff.24,25 Additionally, theColorado initiative used funding to support purchasing equipment and electronic health records for clinicalpartners.24(for text box 19)
Quality Improvement (QI) and Data Monitoring
QI, data monitoring, and evaluation help support evidence-based practices and demonstrate SCAI’s
effectiveness. Some SCAI—such as projects in Iowa, Delaware, and South Carolina—engage an independent
evaluation partner, usually a research institution or consulting firm, to lead evaluation activities. Other
projects often collect data for quality improvement and monitoring in-house.

ASTHO’s SCAI Learning Community Focus Areas of Success:Quality Assurance/Improvement Strategies
Quality assurance and measuring improvements in access to contraception is critical for modifying clinicalpractice, and for monitoring and reporting long-term success and growth. Strategies may include
developing a QI program that integrates clinical performance measures related to contraceptive care,
improving surveillance systems, conducting process and outcome evaluations, establishing agreements toaccess existing data (e.g., Medicaid or hospital records), and developing innovative data collection
methods that provide information to guide implementation of these strategies.
States can perform ongoing data analyses to discover opportunities to strengthen contraceptive
programs, such as identifying providers who need training, service locations that do not provide a fullrange of contraceptive methods, sub-populations or geographic areas experiencing highest need, andways to ensure method satisfaction among clients. 19
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Public Awareness Campaigns
Public awareness campaigns serve as an opportunity for SCAI to increase visibility of their initiatives, discuss
reproductive health topics, and guide potential patients to the initiatives’ reproductive services. Most SCAI
included digital outreach strategies as a part of their public awareness campaigns, such as internet andmedia advertising, social media channels, and innovative digital platforms. South Carolina launched the “No
Drama” marketing campaign to direct potential patients to a website or phone line where they can learn
more about reproductive health topics and schedule appointments at Choose Well-participating clinics. The
marketing campaign used a combination of billboards, radio spots, and social media advertising to increaseawareness of the Choose Well initiative in the state.25
In Illinois, the ICAN! website used interactive features to provide evidence-based and unbiased birth control
information and connect users to services. The website included a quiz in which users could assess andidentify which birth control methods fit their needs and includes a “phone-a-friend" feature for users to
speak with a trusted expert.22 Colorado initiated the Beforeplay campaign, a public awareness campaign foryoung people to encourage them to make healthy sexual decisions.13 The purpose of the campaign was tooffer reliable and easy-to-understand information, normalize the statewide conversation about
reproductive health, and increase the visibility of Title X clinics and other health centers offering affordable
reproductive health services. The campaign was conducted through social media, posters and billboards,
and a website.
SCAI also use non-digital methods to reach potential patients. In Missouri’s The Right Time initiative, thepublic awareness campaign included distribution of promotional materials, such as brochures, postcards,
posters, and palm cards. Additionally, outreach and education coordinators and community mobilizers
engaged in both virtual and in-person community outreach activities to effectively amplify awareness of theinitiative.21
Stakeholder Engagement
The implementation of all the SCAI involve strategic collaborations and partnerships among diverse
stakeholders, including healthcare institutions (e.g., FQHCs, Title X clinics, and hospitals), private and public
insurers, contraceptive device manufacturers, state agencies, local organizations, and community
members.19 Examples of stakeholder engagement and partnership are described below. (b 22 ; 25 ; 26

SCAI Stakeholder Engagement and Partnership Examples• ICAN! in Illinois was guided by a 15-member community advisory board, representing the communities
served by the health centers. ICAN also collaborated with the Chicago public school system and Departmentof Public Health, Illinois Department of Human Services, and local youth organizations to disseminate
education and resources on contraception, along with community-based maternal and child healthproviders and community-based organization staff members to offer training to screen clients forcontraceptive needs. 22• South Carolina’s Choose Well Initiative involved systematic coordination across sectors, including FQHCs,
hospital inpatient and outpatient providers, rural health clinics, free clinics, college and university healthcenters, and the Title X-funded public health departments, community organizations, and higher education
institutions. 25• Utah’s Family Planning Elevated incorporated a diverse network of clinics, including FQHCs, private clinics,
and city and county clinics (Simmons et al., 2020). The project also formed a Reproductive Justice Advisory
Board to “ensure that FPE understands the needs of historically underserved populations and is addressing
access barriers specific to those populations.” 26

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Legislative or Other Public Policy Change
Supporting the passing and implementation of public policy change is essential to systemically supportingand expanding contraceptive access within states. Many SCAI whose efforts are described within this scan
focused their policy initiatives on improvements to Medicaid reimbursement, state family planning funding,and policies to expand the ability of providers to prescribe and dispense contraception. For example, theColorado initiative formed two coalitions that engaged Title X clinics in advocacy efforts, which led to
improvements in Medicaid reimbursement, confidentiality protections, and state funding for familyplanning.24 In the Illinois initiative, implementers focused on implementation and enforcement of existinglegislation, such as supporting the implementation of Illinois’ pharmacy prescribing law and working to
improve components of the state Medicaid program.22
Restrictive state policies can cause barriers to sustainability of an initiative’s activities. In an evaluation ofsite leaders in South Carolina, respondents expressed their concerns about limited insurance coverage forcontraception. Implementers of South Carolina’s Choose Well are exploring various solutions to address
this challenge, including 340B drug pricing, expansion of insurance coverage and reimbursement policies,
and facilitation of patient Medicaid enrollment.27

Challenges and Lessons Learned from Implementation Approaches
Implementation of SCAI can be challenging, as many SCAI are operating within polarized politicallandscapes and under limited capacity among clinical and community partners. This section summarizes arange of challenges faced by SCAI during implementation, as well as lessons learned that may inform future
efforts.
Implementation Challenges and Lessons Learned
Costs and Reimbursement

Clinical Implementation

Political Landscape

COVID-19 Pandemic

Costs and Reimbursement
Although many SCAI provide funding to clinical partners for contraceptive methods, it is important for
initiatives to leverage state and federal funding sources to ensure supply of all contraceptive methods aremaintained after the initiative ends. Reimbursement was a consistent challenge across SCAI, due to boththe inadequacy of reimbursement and the resources needed to train clinic staff to adequately perform
coding and billing. Research evaluating a longitudinal cohort of clinics engaging in Family Planning Elevatedin Utah found that “successful reimbursement requires a tailored approach to education, training, andfollow-up of clinic administrative staff as well as programmatic flexibility to accept and correctly interpret
program billing inputs provided variably.”20
In interviews with clinical partner site leaders for Delaware’s DelCAN initiative, the most common challenge
reported was a lack of clarity on processing payments and billing for services and devices.28 Many siteleaders expressed concerns about double billing, either the insurance companies or patients. Additionally,site leaders in smaller clinical practices worried about the loss of money in scenarios where the patientchanges their mind or does not come in for their appointment.28 Similar billing and coding were
documented in South Carolina’s Choose Well initiative in which staff from the partnering clinics discussed
on-going issues with billing and coding due to complicated coverage and reimbursement policies acrossinsurance policies.27 Both site leaders from the DelCAN initiative and staff from the Choose Well initiative
recommend that ongoing technical assistance for coding and billing is needed to ensure a stock of devices
and supplies are maintained within clinics.

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Clinical Implementation
Oftentimes, SCAI are implemented across diverse networks of clinics with varying administrative policies,
clinical capacity and priorities, and reporting systems.20 These differences among clinics require SCAI
implementers to understand the unique needs of clinics and tailor the initiative to meet those needs. When
discussing the challenges faced in Utah’s initiative, the implementers emphasized the importance ofintervention designs being cognizant of “initiative fatigue” to ensure participation, completion, andcompliance.20 In the evaluation of site leaders for DelCAN’s initiative, many leaders discussed how they
were initially enthusiastic about the implementation of the initiative, however their enthusiasm waned asthey tried to address multiple logistical challenges.28 Site leaders discussed facing multiple difficulties in
implementing the initiative’s activities, including challenges with preceptorship for providers and changes
to the practice workflow to accommodate same-day insertions of methods of LARC.28
Clinical partner site leaders in Delaware emphasized the need for more inclusive communication at multiple
levels and cultural humility in communication with patients. They recommended an initial assessment ofclinics, a pre-implementation phase prior to the training, and more conversations about the initiative with
providers and staff across roles.28 The site leaders believed this would allow for more tailoring of theinitiative to the wide range of clinics and establish a smoother transition from training to implementation,
which ultimately can lead to more buy-in across the clinics.28
Research on an initiative to implement IPP LARC in rural New Mexico found that clinical champions were amajor facilitator and drove efforts at every hospital that made progress in implementation. They also foundthat multidisciplinary teams are critical to complete implementation steps, including active participation ofadministration, pharmacy, nursing, and clinical staff.29
Political Landscape
SCAI operate in varying political contexts which can impact the implementation of project activities. The
Right Time initiative in Missouri described how the political climate in Missouri and the overturning of Roev. Wade limited the ability for implementers to pursue proactive contraceptive legislation due to thepolarized environment around reproductive healthcare.21 Implementers also described needing to combat
the spread of mis- and disinformation among legislators. The Right Time initiative has increased outlets forbroader dissemination of high-quality contraceptive information to help counteract distrust and myths
about birth control services. Additionally, staff have created messaging for legislative decision-makers
showing the benefits of contraceptive-friendly policies and regulations.21
COVID-19 Pandemic
Initiatives in Illinois and Missouri described the effects of COVID-19 pandemic on implementation inmaterials identified in the environmental scan. In Illinois, the ICAN! Team found that the COVID-19
pandemic further exacerbated barriers for people of color and people with few resources when accessing
contraceptive care at physical health centers.30 To address this challenge, the initiative focused onincreasing access points beyond the health center and planned to include more in-person community
outreach and train community-based social service providers on screening for clients' contraceptive needs
and desires.30
In Missouri, the availability of services declined at more than half of the initiative’s health centers due tothe centers shifting to COVID-19 testing, vaccination, or contact tracing.21 Additionally, the concerns about
COVID-19 exposure led to fewer people seeking reproductive health services. Lack of access to reliableinternet in Missouri also meant about one-third of the population in Missouri had limited access totelehealth services, which worsened existing health disparities. The challenges led the implementers toreimagine elements of the initiative and create new opportunities to support the community. For example,
many health centers served as food distribution sites and social support centers. The integration of social
5

service delivery in a healthcare setting created a venue for implementers to increase outreach and uptakeof contraception and an environment promoting family health and well-being. Additionally, health centersprovided alternate care delivery, including “curbside contraception pick-up and mailing, drive-throughDepo-Provera clinics, and technologies for mail-order contraception.”21

Evaluation of Statewide Contraceptive Access Initiatives
Evidence identified in the environmental scan indicated that SCAI use a range of shared measures toevaluate various components and levels of the initiatives. SCAI projects included in the scan were at varying
phases of data collection and analysis, and available resources ranged from published findings oncompleted projects, to evaluation methodologies and early findings from ongoing initiatives.

Summary of Evaluation Outcomes
Outcomes of interest focused on healthcare providers and health centers, clients and potential clients,
health and social outcomes, and public policy outcomes, are described below and outlined in Table 3.
Table 3. Overview of SCAI Measures/Outcomes of Interest
Level
Measure/Outcome• Service expansion
Health Centers and Healthcare• Provider changes in knowledge, skills, attitude, and beliefs
Providers• Perceived barriers and opportunities• Service utilization
Clients and Potential Clients• Patient-reported experience of care
• Contraceptive use• Reproductive autonomy and other person-centered measures• Unintended pregnancy
Health and Social Outcomes• Birth and fertility rates• Abortion rates• Maternal health and infant health• Medicaid enrollment and policy change
Public Policy Outcomes• Cost savings
Health Centers and Healthcare Providers
The environmental scan identified publications describing measures of interest related to SCAI partnering
health centers and healthcare providers, including increased service offerings, clinical capacity, and theeffect of training and technical assistance on provider knowledge, skill, perceptions, and care delivery. The
available evidence demonstrated how SCAI contribute to changes in care delivery practice forcontraception as well as perceptions of expanded contraceptive access among clinical staff. These studies
reported that organizational factors, sustainability of funding, and training are key to realizing the fullpotential of these initiatives.
Service Expansion in Health Centers. One study and two midline evaluation reports described service
expansion in health centers as a result of SCAI implementation, including offering the full range ofcontraceptive methods. The Iowa Initiative found that the 17 participating Title X clinics used funding to
implement changes to expand services and reach, including: 82% (14) added a new marketing strategy; 76%(13) added practitioners; 59% (10) added the contraceptive implant; 59% (10) added the ParaGard IUD; 59%(10) expanded clinic hours; 53% (9) added the Mirena® Intrauterine system; 53% (9) added clinic locations;
47% (8) hired interpreters; 35% (6) increased their walk‐in hours; and 29% (5) added educators orcounselors.12

6

In a study of midline evaluation findings, researchers from the Choose Well initiative reported significant
increases in the ability of partner FQHCs to stock and provide contraceptive methods through the initiative.
Data comparing FQHCs that participated in the Choose Well initiative to those that did not showed that onsite provision of the full range of contraceptive methods, particularly IUDs, increased significantly inparticipating health centers. The percentage of participating FQHCs offering any IUD onsite increased from
37% at baseline to 85% at midline. Researchers noted the significance of this finding, given the cost andclinical challenges of onsite provision of IUDs, in addition to IUDs being the least likely method provided at
South Carolina FQHCs at baseline.31
A midline evaluation of the Right Time initiative in Missouri found that financial support from the SCAI
enabled more health centers to have contraceptive methods in stock. On average, stocked methods
increased from five of fourteen contraceptive methods at baseline to right of fourteen methods at 18
months into implementation. More health centers stocked more costly short-term methods, such as thering, as well as IUDs and implants at midline. Qualitative data also suggested that increased affordability
and coverage of contraceptive services through the initiative’s financial support expanded the options
providers offered to patients due to less concern about cost.21 Additionally, the number of health centersthat offered same-day access to IUDs increased from one of twelve surveyed health centers at baseline to
five of twelve health center at midline. Similar trends were observed for the patch, Depo-Provera shot, andNuvaRing. Same-day LARC placement increased from 72% at 6 months to 84% at 18 months, among people
requesting LARC.
Outcomes Related Healthcare Providers. The scan identified eight resources describing outcomes related
to healthcare providers and staff. One study described changes in the number of contraceptive careproviders during the New Mexico initiative. The initiative found that the number of providers rendering
contraceptive care to adolescents and young women, reimbursable by Medicaid, increased 20-fold andfour-fold, respectively, during the initiative.32 Researchers conclude that an increase in Medicaid-rendering
providers helped expand access to contraceptive services, especially in rural areas.32
Other studies described surveys and qualitative interviews with clinical leaders and staff, healthcare
providers, and nursing students to understand changes in perceptions, knowledge, skills, and beliefs about
contraception and contraception access, associated with implementation of a SCAI. In Delaware,
researchers conducted semi-structured interviews with 32 leaders from 26 practice settings participating in
the initiative to identify common themes in implementation experiences. Results showed that mostpractices found an increase in patients requesting LARC methods during the initiative.28 These practices also
reported needing significant flexibility to respond to and adapt their contraceptive access interventions to
fit the needs and constraints of their settings and patient populations. Practice settings with greater preexisting capacity found it easier to offer the full range of contraceptive care than practice settings with lesspre-existing capacity; those that faced more barriers included primary care practices, smaller practices, andpractices that served large numbers of adolescents. The study noted that addressing logistical challenges,
particularly around billing, is key to expanding contraceptive access in clinical settings. 28
In South Carolina, one study examined perceived clinical and administrative facilitators and barriers related
to contraceptive access among staff at Choose Well-participating FQHCs. Data from 34 interviewed staff
found that the most notable clinical facilitators for contraceptive access were increased capacity forcontraceptive counseling and provision through training, external funding for IUDs and implants, andstreamlining workflow processes.27 Buy-in and engagement among clinic staff and leadership were noted as
facilitators for some clinics and a barrier for others. Policy and structural factors related to costs of devices
and insurance coverage were also among the noted barriers, and threatened sustainability of theinitiative.27 An endline survey was planned for 2023.25

7

Another study on the Choose Well initiative described the feasibility of providers to translate knowledge
and skills gained from contraception trainings into improvements in practice, by measuring their intent tochange their practice post-training and potential barriers to implementing change. The research suggested
that the initiative’s trainings were successful in influencing providers’ intent to improve contraceptive carepractices, with 80.7% (n = 2,390) of respondents indicating intent to change and 35.5% (n = 1,044)
anticipating barriers to implementing intended changes.33 The most common barriers to practice change
were described as organizational factors (e.g., time constraints, policies and practices,
infrastructure/resources) and structural factors (e.g., cost for patients for IUD and implant provision).33
Two additional studies related to the Choose Well initiative assessed the effect of hands-on LARC andreproductive health trainings among family nurse practitioner students at four public colleges of nursing.
With funding from Choose Well, the colleges incorporated reproductive health content in the corecurriculums of their master’s and doctoral nursing programs. Anecdotal information gathered fromstudents in 2019 and 2020 indicated the trainings better equipped the students to discuss reproductive
health options and insert and remove IUDs and implants. 17 Students also reported improved perceptions
about LARC, intra- and interprofessional opportunities, employment opportunities, and improved salarynegotiation.17 In a post-graduation cross-sectional survey conducted in 2021, nursing school graduates
reported that opportunities to reinforce learning through simulation and clinical placement contributed toincreased comfort, confidence, and competency in LARC insertion and removal, as well as a strong level ofsatisfaction with the training curriculum.18
A midline evaluation of the Right Time initiative in Missouri described qualitative and quantitative findings
related to provider awareness of contraceptive methods and confidence with person-centered counseling.
At 18-months into implementation, many interviewed health center staff reported the initiative helped
increase their knowledge and skills across different methods, as well as multiple dimensions of culturallycompetent care. Qualitative data suggested that increased awareness and specialized training enabledproviders to confidently address LARC myths, counsel patients on their options, and place and remove
LARCs. Quantitative data, however, showed decreases in the percentage of surveyed providers whoreported being “very comfortable” with varying contraceptive methods. The researchers described staff
turnover as the likely cause for the reduction and suggested the need for additional training oncontraceptive methods and person-centered care based on the data.21
A study of both the Colorado and Iowa initiatives surveyed 159 clinicians, including physicians, physicians'
assistants, nurse practitioners, certified nurse midwives, and registered nurses, in 47 family planning
agencies across both states in 2010. Researchers found that clinicians' beliefs around immediate postpartum contraceptive or post-abortion use and use with menorrhagia or dysmenorrhea differed fromclinical guidelines. Clinicians were also hesitant to recommend IUDs and implants to some groups ofpatients.34 Findings from Colorado and Iowa suggest that provider perceptions, attitudes, and bias may bebarriers to contraceptive use, that professional and in-service training may help address.34
Clients and Potential Clients
Evidence identified in the scan on outcomes related to clients and potential clients focused on:•Service utilization by describing clinic visit data.

•

Patient-reported experience of care by exploring experiences receiving person-centered care fromhealthcare providers.

•Contraceptive use by exploring LARC use, postpartum LARC uptake, contraceptive method mix, anddiscontinuation rates.

8Service Utilization. Data describing service utilization were identified for the Colorado and Indiana
initiatives. The Colorado Initiative, which was implemented in Title X clinics, found the total number ofwomen seen in Title X clinics increased by 2.5% during the initiative.24 Descriptive data from Indiana’s
PATH4YOU showed that 1,024 people received care at 1,231 visits between September 2021 and June
2023, and most patients received contraceptive care in one in-person (66.0%) or telehealth (17.9%) visit.35
Patient-Reported Experience of Care. The scan identified one report with tentative patient survey datafrom South Carolina’s Choose Well initiative and one study of patient experience from South Carolina’s IPP
LARC effort. The Choose Well patient study is underway with peer-review and publication expected in the
future. A midline evaluation summary described that, between 2018 and 2021, 2,027 patients fromparticipating and non-participating clinics were surveyed before their contraceptive care visit about theirgoals and expectations, and after their visit about their experiences. Surveys were designed to assess
whether patients received high-quality, person-centered contraception care by asking whether they
discussed key reproductive health topics with their providers and whether their provider showed them
respect and counseled them in a patient-centered manner. Questions related to provider respect andpatient-centered contraceptive counseling included whether individuals perceived that their provider: is
looking out for the patient’s best interest, clearly respects the patient as a person, took the patient’s
preferences about contraception seriously, gave the patient the information they needed to choose thebest method for them, and let the patient say what mattered to them about their contraceptive method.36
Results found that most patients from both participating and non-participating clinics reported that theirprovider discussed these key topics with them. Greater percentages of patients from participating clinics,
compared to patients at non-participating clinics, reported that (1) their provider discussed possible side
effects and the safety and efficacy of IUDs and implants; and (2) they completely agreed that their provider
was very knowledgeable about birth control. Similarly, greater percentages of patients from participating
clinics completely agreed that their provider clearly respected them as a person, took their preferences
about contraception seriously, and let them say what mattered to them about their contraceptive
method.36
A study of patients’ experiences with IPP LARC counseling and use during South Carolina’s Medicaid policychange was conducted in 2016 to 2018. Findings indicated that some patients were dissatisfied with
providers’ approaches to counseling because they either did not receive enough information or felt
pressured to use a LARC method. Some objected to the timing of the counseling, and three of ten patients
who elected to receive IPP LARC later desired removal and encountered barriers. This study suggests that
the IPP LARC counseling may not have been sufficiently person-centered and lack of access to barrier-free
LARC removal limits patients’ reproductive autonomy, indicating the need for additional counseling training
and increased care coordination.37
Contraceptive Use. Studies identified in this scan assessed contraceptive use across nine initiatives: sevencontraceptive access projects and two postpartum LARC initiatives. All studies described changes in use of
LARC, and most described overall contraceptive use, including method switching. Some studies examined
the association between the initiative and contraceptive use changes, and described use across different
patient characteristics, including age and coverage (e.g., Medicaid enrollees). Findings from these studies
are summarized in Table 4 and suggest that SCAI are an effective strategy for increasing initiation of LARC
methods.

9

Table 4. Summary of Evidence on Contraceptive Use
State
Summary of Evidence on Contraceptive Use• Increase in LARC use among 14-24 year-olds in Title X clinics from 5-19% 23• Increase in LARC use among women under 30 – from less than 3% for under 18 year-olds
and 7% for 20-29 year-olds, to nearly 30% for the under 30 age group 38
Colorado• Increase in proportion of female contraceptive clients using LARC from 6% to 32% from2008-2019; decrease in proportion of clients using combined hormonal methods (48% to25%); no change in Depo Provera use 24• Increase in overall LARC use from 4.1% in 2008 to 25.0% in 2017; increased LARC use
associated with DelCAN initiative 2• Increase in LARC adoption among adolescents, from 33% in early project phase to 68% inlater period; no significant change in adult LARC adoption 39; increase in LARC among
Delawareadolescent Medicaid enrollees 40• Increase in number of same-day LARC encounters, particularly for contraceptive implants41• Decrease in use of hormonal methods (e.g., pill, patch, ring) from 2008-2014 42; decline inany method initiation among Medicaid enrollees from early project phase to later period 39
Indiana• Most common primary methods of contraception used were implants (25.8%),
contraceptive pills (20.5%), and intrauterine devices (16.0%) 35

Iowa• Increase in IUD use among women in Title X clinics by 218% from 2007-2010; increase in
implant use by 829% 12

Missouri• Higher rates of contraceptive use among patients in the initiative (96%) compared to statelevel estimates of contraceptive use in Missouri (69%) for women ages 18-49 21• Increase in uptake of birth control pill (10% increase), Depo-Provera (5%) and LARC (3%);
decrease in male condom use and abstinence as primary contraceptive methods 21• Increase in contraceptive switching (3% increase in switching from other method to LARC
method), following efforts to eliminate cost barriers6/11/2024 7:25:00 PM

New Mexico• Increase in LARC use among Medicaid-enrolled women 24 years and younger; overall
greater increase in moderately effective method (e.g., pill, patch, ring) users than increasein LARC users 32

South
Carolina• Increase in LARC use (8.5% to 10.9%) and decrease in short-acting hormonal contraception(45.7% to 40.6%) from baseline to midline intervention; IUD initiation primarily among
women 20-25 years-old; increased IUD use attributed to Choose Well initiative 43

Utah• Most (70%) women reported continued LARC use at six-month assessment; high rates of
discontinuation among women using short-acting methods, 36.9% of which switched to
LARC 44• No difference in LARC use among securely housed and insecurely housed women during
no-cost contraception intervention period, compared to higher LARC use among insecurely
house women during control period 45• Lower use of barrier methods, emergency contraception, and no documented
contraception and higher use of more effective methods among women visiting
participating HER Salt Lake clinics, compared to women visiting non-participating clinics 4

IPP LARC
Initiatives• Increase in postpartum LARC insertions (259% increase) among women in South Carolina
after implementation of Medicaid policy change46; increase in IPP LARC use among adults
and adolescents for all hospital inpatient births, relative to that expected without thepolicy change 47• Uptake of LARC post-delivery among women who wanted to delay childbearing at a
hospital offering IPP LARC in Texas; limited LARC access among women in hospitals that did
not offer IPP LARC 48

10

Health and Social Outcomes
Health and social outcomes assessed among SCAI and identified in the environmental scan include
reproductive autonomy, unintended pregnancies, fertility rates, abortion rates, and maternal and infant
health outcomes.

Limited Evaluation of Equity-Focused Outcomes
While there continues to be limited evaluation of reproductive autonomy, person-centered counseling,and sexual and reproductive health equity outcomes in SCAI, this scan found one study from Utah’s FPE
initiative related to reproductive autonomy. Similarly, initiatives in Missouri and Illinois reported shifting
to more person-centered evaluation and focusing on outcomes outside of unintended pregnancies.

Reproductive Autonomy and Other Person-Centered Measures. The FPE initiative in Utah examinedfeelings of control over pregnancy as one indicator of reproductive autonomy.49 They used survey datafrom young women 18-24 years old eligible for the FPE initiative to assess their level of agreement with thefollowing statement: “I feel that I have control over whether or not I get pregnant” and its relationship withsociodemographic characteristics. The study found that 86% of women agreed with the statement, with theremainder of participants responding with neutral or disagree. Neutral responses were more likely among
participants who reported poverty-level incomes and previous unwanted pregnancies.49
The ICAN! initiative in Illinois has reported plans to focus on person-reported outcome performancemeasures, including the Person-Centered Contraceptive Counseling (PCCC) measure, in the evaluation tomeaningfully assess reproductive autonomy and wellbeing.22 The evaluation plan also included use of
PRAMS data to assess changes in mistimed or unwanted pregnancies where the patient had apreconception healthcare visit.50 No data had been reported at the time of this scan. The Right Timeinitiative in Missouri has also reported plans to assess reductions in mistimed or undesired pregnancy. 21
Unintended Pregnancy. Data on reducing unintended pregnancy was identified for three statewide
initiatives – Delaware, Iowa, and South Carolina. According to modeling performed by ChildTrends related
to the DelCAN initiative in Delaware, researchers estimated a substantial reduction in unplanned pregnancy
among the population studied.42 PRAMS data indicated a 25% reduction in births from pregnancies wanted
later or not wanted in Delaware from 2014 (baseline period) to 2017.51 An article identified in the scan
noted that an independent evaluation assessing the effect of DelCAN on unintended pregnancy rates
statewide is underway.28
In Iowa, data from the Iowa Department of Health and vital records indicated the percentage of unintended
pregnancies declined 14% between 2006 to 2011. Additionally, the decline in unintended pregnancies in
Iowa was greater than other Midwest states between 2005 to 2008.52
The Choose Well initiative in South Carolina aimed to have a 25% reduction in statewide unintended
pregnancies by 2022. Unpublished data from the South Carolina PRAMS in 2020 suggested a 44% decreasein unwanted births across the state.53,54
Birth and Fertility Rates. The scan identified one initiative that reported data on birth and fertility rates,
particularly among adolescents and young women - the Colorado Initiative. From the start of the initiativein 2009 to 2016, Colorado’s teen birth rate dropped 54% from 37.5 births per 1,000 teens in 2009 to 17.1 in2016.55 The number of repeat teen births (i.e., teens giving birth for the second or third time) dropped 63%

11between 2009 and 2016, and the average age of first birth increased by more than a year among all women
between 2009 and 2016.55 Research indicated that after the CFPI, births to 15-17 year-olds fell
approximately 10% more for zip codes within five miles from a Title X clinic, compared to those living in zip
codes greater than 20 miles from a clinic.38 A separate study found that the fertility rate in Colorado
dropped 48%, from 37.4 births per 1,000 women in 2009 to 19.4 births per 1,000 women in 2014.13
In a study on Colorado’s outcomes at the five-year follow-up period, the initiative reported on the declineof adolescent birth rate in the state, from 11.2 per 1,000 in 2008 to 3.9 per 1,000 in 201924. However, it
should be noted that the project faced criticism for justifying increased funding for promoting LARC-firststrategies and justifying the project based on costs avoided by governmental programs after a decrease inadolescent birth rates was seen in the state.13,24
Although data has not been reported to date, Illinois and South Carolina’s evaluation plans described
assessing public health surveillance indicators related to birth rates from state and local vital records datain their evaluations.25,50
Abortion Rates. Evidence on abortion rates were identified from three initiatives (CO, DE, and IA). Researchfrom the Colorado initiative reported the abortion rate fell 63% among women ages 15-19 years, and 41%
among women ages 20-24 years between 2009 and 2016.55 In a five-year follow-up evaluation, the initiative
reported a decline from 39.6 per 1000 in 2008 to 13.5 per 1000 in 2019.24 In Delaware, a 2017 report fromthe Guttmacher Institute found that from 2014 to 2017 during the period that the DelCAN initiative was inplace, Delaware experienced a 37% reduction in abortion rates.56 Finally, in Iowa, the number of abortions
decreased by 19% between 2007 and 2010 when the initiative ended. 12 A later report indicated thepercentage of pregnancies in Iowa terminated by abortion declined by 21% between 2006 and 2011.52
South Carolina has included abortion rates as a part of their planned health and social outcomes, leveraging
state level vital records data, but no data has been reported to date.25
Maternal and Infant Health. This scan identified studies that examined maternal and infant health,including birth spacing, in Colorado and South Carolina. Findings from Colorado’s initiative indicated thatthe project contributed to an increase in average maternal age at first birth, reduced the proportion of allbirths to mothers without a high school education, reduced the number of births to unmarried women
under age 25 without a high school education, reduced the number of repeat births to young women, andincreased the length of time between births.13
Research from South Carolina’s IPP LARC effort, prior to the Choose Well initiative, studied the association
between Medicaid payment change for IPP LARC and a change in birth intervals. Findings indicated thatadolescent short-interval births were increasing before the policy change and flattened afterward. There
was no statistically significant change in trend in short-interval births for adults following the policy change.
Researchers concluded the need for further study.47
Regarding adverse pregnancy outcomes, researchers in Colorado indicated that a statistically significant
decrease in preterm birth (PTB) between 2008 (pre-initiative) and 2012 (during initiative) for the state ofColorado. Researchers compared Low Birth Weight (LBW) and PTB in 2008 and 2012, in counties with andwithout Title X clinics, and then compared the relationship between LARC use and the incidence of LBW or
PTB in 2012 for women living in counties with Title X clinics. They found that living in a county with a Title X
clinic with the highest degree of LARC use at the peak of the Colorado Initiative was associated withdecreased odds of PTB. There were no statistically significant results for LBW babies.3

12

Public Policy Outcomes
Medicaid Enrollment and Policy Change. One study in Utah assessed changes in Medicaid enrollment.
Despite the initiative’s goal to support clinics to enroll newly eligible Medicaid clients, researchers foundthat the proportion of Medicaid eligible patients at the clinics remained largely unchanged after the
initiative's implementation.57 Researchers identified “application burden, enrollment requirements, andlack of presumptive eligibility” as challenges for Medicaid utilization.57
Other studies related to Medicaid policy change studied Medicaid agencies’ experiences with implementing
payment for postpartum LARC58 and outlined implementation approaches for successful implementation of
postpartum LARC access projects.59,60
Cost Savings. Regarding savings to public programs, an analysis by health economists at the University ofColorado contracted by the Colorado Department of Health found that between 2010 and 2014, between$66,063,664 and $69,625,751 were saved in costs to entitlement programs, such as Medicaid, Temporary
Assistance to Needy Families, Supplemental Nutrition Assistance Program, and Special Supplemental
Nutrition Program for WIC due to reductions in teen and unintended pregnancy.13 In Colorado, theoutcomes of the initiative are believed to have led to a significant increase in the state’s family planningbudget 13ost. Although these cost-savings data are cited as the primary reason for the Colorado statelegislature approving a significant increase to the state family planning budget, from an equity perspective
these types of rationale for contraceptive access initiatives may be harmful.61

Sustainability
An important goal for SCAI is to build sustainable capacity for contraceptive care after project activities andfunding ends. Sustaining an initiative after private funding ends can be challenging for initiatives that havedepended on the scale of funding, as implementation and evaluation can be resource intense. Informationin the current literature about approaches to SCAI sustainment is limited, as some of the initiatives are stillin progress.
However, some initiatives included in this scan reported that sustainability was considered throughout theplanning and implementation of project activities, such as leveraging payers and coverage to fund accessactivities, building and engaging a coalition of committed organizations, building workforce knowledge andcapacity through provider trainings, and advocating for legislation that supports increased access to highquality, affordable family planning services. The literature highlighted various SCAI approaches tomaximizing funding, extending timelines, and advocating for legislative and policy change, and the potential
positive impact of receiving tailored technical assistance on sustainability as part of a learning community.
Further research is needed to understand how, and to what extent SCAI, have (or have the potential to)sustain change after the initiatives have ended.
Funding Approaches
Both the SCAI in Massachusetts62 and New Mexico32 described the importance of receiving buy-in andfunding support from government agencies, such as the state health department and the state Medicaid
program, for the purposes of sustaining the delivery of contraceptive services.
One initiative, ICAN! In Illinois, described its approach to funding health centers, different than otherinitiatives, aimed at achieving long-term sustainability. Instead of providing funding to clinical partners to
support the provision of low- or no-cost contraceptive methods, the initiative focuses on “shifting payer
practices to reward contraceptive care provision, expanding coverage for individuals with few resources,
and supporting health centers in maximizing revenue from contraceptive care services through accurate
billing and coding practices.”2213Extended Timelines
In a midline evaluation report, representatives of The Right Time Initiative in Missouri described how SCAI
are often functioning in an evolving and dynamic environment that can create challenges for sustaining theinitiative's efforts, including the COVID-19 pandemic, a polarized political climate, and misinformation ofcontraception.21 The implementers of the Missouri initiative have approached this by extending both healthcenter participation and community mobilization activities to provide more time to improve and sustain theinitiative’s project activities.21
Building Capacity
SCAI have incorporated training and technical assistance in their core intervention components to support
building the knowledge and capacity of the contraceptive care workforce. Choose Well in South Carolina
has made training recordings available online that cover a range of topics, such as patient-centered careand sustainability.63 The initiative also developed a toolkit to support community health centers broadly toincrease access to contraception. The toolkit details changes health centers can make to operational andadministrative systems, clinical services, financial systems, and sustainability to improve access, including
tips and resources. It also describes how a coordinating organization can support multiple health centers toattain their goals.54
Legislative Advocacy and Policy Change
SCAI also focused efforts on improving existing legislation or advocating for new legislation to sustain
contraceptive services within the health system. For example, in Illinois, implementers sought to increase
access points for contraceptive care by introducing an amendment to a new pharmacy prescribing law
seeking to establish high-quality care and referral protocols and influence pharmacist training standards.22
In Utah, implementers discussed how policies can provide improvements for access to care, however, they
stressed the importance of policies including an adequate budget and plan to ensure successful
implementation and, ultimately, sustain change in the healthcare system.57 The Utah initiative experienced
challenges with policy implementation through the state Medicaid expansion, following low utilization of
Medicaid reimbursement for family planning services at the initiative’s clinical partner sites.57
Participation in ASTHO’s Learning Community
ASTHO’s multi-state Increasing Access to Contraception Learning Community was convened during October
2016 through May 2018, and was evaluated by the University of Illinois at Chicago, with a focus on theimplementation outcomes of sustainability and acceptability.8 The learning community focused on nine key
areas of SCAI implementation and evaluation: provider awareness and training; reimbursement andfinancial sustainability; informed consent and ethical considerations; logistical, stocking, and administrative
barriers; consumer awareness; stakeholder partnerships; service locations; data, monitoring, andevaluation; and specific populations. A year after the Learning Community ended, data collected from 26 of
the 27 participating jurisdictions indicate that teams were sustaining efforts made for 87% (n = 69) of goals
identified in their action plans and work on at least one goal was sustained in every jurisdiction.8 Thesefindings suggest that participation in learning communities and technical assistance opportunities for SCAI
implementers and evaluators can help sustain progress on goals, even when the collaborative has ended.

14

Applying Equity-and Justice-Focused Frameworks in Statewide Contraceptive Access
Initiatives
In the evolving landscape of sexual and reproductive health (SRH) care delivery in the US, interrelated
barriers (e.g., political, geographical, and economic challenges) continue to threaten equitable
contraceptive access. A number of articles emerged in the scan calling for a deeper examination of harmful
assumptions, ideologies, and provider-patient relationships in the implementation and evaluation of SCAI.
For example, experts described how policy and practice approaches that problematize (by prioritizing the
reduction of) unintended and adolescent pregnancies perpetuate the narrative that the reproduction ofsome people (particularly Black, Indigenous, and people of color and individuals living in poverty) is lessvaluable than the reproduction of others.61 Discourse that promotes the prevention of unintended
pregnancies and increased contraceptive access as a strategy to reduce poverty continue to perpetuate
stigma, particularly against young people and individuals with low-incomes, and neglect to address the true
structural causes of poverty, such as systematic racism and economic inequity.61,64 Additionally, thepersisting emphasis of LARC as “first-line” contraceptive methods across various programs and policy
initiatives continue to undermine reproductive autonomy and result in women reporting feeling pressured
by medical professionals to get or keep a LARC.14,65
In response to these challenges, several articles identified in the environmental scan outlined opportunities
for SCAI to draw from equity-centered perspectives and proposed innovative approaches aimed to address
systemic barriers and supporting all people in reaching their self-determined sexual and reproductive goals.
These proposed approaches are described in Table 5.
Table 5. Proposed Frameworks for Sexual and Reproductive Health with Application to SCAI
Framework/
Approach

Description

Example Application in SCAI

Sexual andReproductive
Health andWellbeing66• Described as “a self-defined state that
includes reaching one’s individual sexual andreproductive goals”• Recognizes the need to de-silo clinical care,public health programming, and policy andadvocates for the integration of a wide
spectrum of health services and social
supports• Seeks to incorporate services beyond SRH
services, including maternal and child health,fertility, childcare, paid leave and housing• Redesigning clinical practice and training tosupport increase in access to equitable SRH
care, empower individuals who have faced
harm and barriers in the healthcare system,and prepare clinicians to deliver patientcentered and trauma-informed SRH careand services in a way that reflect a holistic
approach to health and wellbeing• Requires systemic changes to ensure that allindividuals, regardless of age, gender, race, orother intersectional identities, have equitable
access to the resources necessary forachieving their reproductive goals• Policies, programs, and services must center
the needs of those most harmed by inequities
and eliminate the influence of historical andcurrent forces that limit an individual’s ability
to attain SRHW

• Examining and changing existing structures,prioritizing the inclusion of diverse voices,building accountability into systems andprocesses, and aligning language anddefinition with values• For example, the unintended pregnancy
framework, which SCAI often incorporate
into their overall approach and evaluationplans, could be replaced with patientcentered outcomes that prioritize bodily
and reproductive autonomy

Sexual andReproductive
Equity66

15

Framework/
Approach

Description

Example Application in SCAI

Reproductive
Wellbeing67• Described as “all people having equitable
access to information, services, systems, andsupport they need to have control over theirbodies, and to make their own decisions
related to sexuality and reproduction
throughout their lives”• Achieved through four key systems-leveldomains: policy, education andcommunication, healthcare and social services
delivery, and health equity• Implementing community-driven initiatives
with strategies based on the four key
systems-level domains: policy, educationand communication, healthcare and social
services delivery, and health equity• Recognizing that communities are best
positioned to determine the specificinterventions needed to increaseawareness and access to contraceptive
methods

Adopting
Reproductive
Justice
Principles68• Recognizes how historically prevalent
contraceptive frameworks continue toperpetuate coercive policy and clinicalpractices• Involves understanding a community’s history
and challenges, developing trusting andpower-sharing relationships with
communities, and recognizing communities asdecision makers in the design andimplementation of policies, programs, andcare• Meaningfully collaborating with
community-based leaders in Reproductive
Justice organizations who are already
reimagining and transforming how
contraceptive care, policy change, provider
training, and contraceptive methods
counseling are conceptualized,
implemented, and measured

RESEARCH GAPS AND IMPLICATIONSThis environmental scan summarized available evidence on the implementation and evaluation of SCAI thatare completed and in progress. The available evidence demonstrated that most initiatives have common
implementation strategies, including training, provision of low/no-cost contraceptives, patient education
and awareness campaigns, partnerships, equity focus, and policy change. Evidence from this scan suggeststhat the evaluation methodologies, data, and analyses of initiatives are more wide-ranging. The body ofevidence is growing, but additional research is needed on areas outlined below, and in Table 6.
Table 6. Overview of Gaps and Needed Research
Gap

Needed Research

Full Range of
Methods

Explore ability of SCAI to increase access to and uptake of a broad range of contraceptive
methods, beyond LARC

Equity-focused
Approaches

Document and assess how strategies to integrate person-centeredness, reproductive
autonomy, and equity into the design, implementation, and evaluation of SCAI better meetpatient needs and affect outcomes and impact

Project
Comparisons

Investigate how these projects compare and whether the variances between projects might
result in differences in outcomes

Policy Change

Explore the impact of changes related to policies governing Medicaid reimbursement
and state family planning funding on SCAI and potentially support sustainability.

Delivery of the Full Range of Contraceptive Methods
The most common evaluation measure among SCAI was contraceptive use, with a focus on LARC uptake.
Evidence on outcomes from these projects demonstrate that SCAI have been effective at increasing uptake
16

of LARC methods. Some evidence exists demonstrating that SCAI are successful at increasing uptake ofother contraceptive methods and access to contraceptive services. While an increasing number of
initiatives have reported findings related to initiation and use of varied contraceptive methods, there is a
paucity of research examining overall contraceptive use and whether people are receiving thecontraceptive method of their choice as a result of these projects. The available research demonstrates theprioritization of LARC uptake in SCAI, despite the evolution of more recent initiatives prioritizing access tothe full range of contraceptive methods and expressed commitment to contraceptive choice and meetingpeople’s individual contraceptive needs.
Equity-Focused Approaches
Research gaps remain around documenting the design, implementation, and impact of SCAI, particularly in
relation to SRHE. The published evidence on the outcomes of the SCAI is just beginning to reflect theevolution of the SCAI to broader focuses on person-centeredness, reproductive autonomy, and equity.
Measures of contraceptive choice, access to all contraceptive methods (including access to removal ofcontraceptive methods as desired), quality of contraceptive care, and person-reported measures ofexperience are lacking in the current evidence. While many initiatives assess their effects on contraceptiveuse, there is still a need for future research to examine whether increased contraceptive uptake or methodchanges resulted from improvements in access or changes in person-centered quality of care (e.g.,counseling styles and provider proficiency). There is also a need to look at a broader and more nuanced
range of health outcomes, beyond unplanned pregnancy, birth rates, and abortion rates, that can explore
domains like unmet need, pregnancy acceptability, sexual and reproductive wellbeing.

Lack of Research on Equity-Focused Approaches
This scan did not identify research that explicitly examined racial inequities in contraceptive access, theinfluence of coercion on contraceptive choice, improvements to racial and ethnic gaps in contraceptive
access, improvements in contraceptive access for communities of color and other communities facing
barriers to care, or pregnancy or maternal health outcomes of diverse communities.

Given that SCAI evolution was partly attributed to an increase in awareness of racial inequities andreproductive justice, it would be useful to evaluate whether these changes led to increased access andreproductive autonomy. Future research should evaluate if contraceptive use related to SCAI are alignedwith individual preferences and reproductive goals and assess patient experiences as well as the quality ofcontraceptive counseling to ensure patients’ preferences and choices are respected.
Project ComparisonsPeer-reviewed publications comparing outcomes between states that have implemented SCAI, or whether
variations in project implementation, funding, or other key aspects might result in differences in outcomes,
were not identified in this scan.
Policy Change
Given the critical importance of policy to SCAI success, research on the effects policy changes related to
SCAI is limited in the evidence. Additional research on policy changes related to Medicaid reimbursement,
state family planning funding, and other issues may expand the body of evidence and foster support for thesustainability of these projects.

17CONCLUSION
Findings from this environmental scan demonstrate that SCAI across the U.S. implement strategic,
multilevel interventions that can help increase access to and utilization of contraception. As these initiatives
continue, additional analysis might be beneficial to support their utility. Reframing measurement andanalysis from a reproductive justice lens, expanding research on policy implications, and examining thesustained effects of these projects may be important perspectives to foster continued support of SCAI.
Table 7. Summary of Key Takeaways from the Environmental Scan
Domain

Key Takeaways•

Origin and
Evolution••

Implementation

Evaluation

•

•
•

•
Sustainability••
Research Gaps•

Thirty states and/or territories have implemented, or are currently implementing,contraceptive access initiatives that are documented in the published literature, including
the 27 states and/or territories that participated in ASTHO’s multi-state contraceptive
access learning community.
SCAI are an important intervention to increase access to contraceptives, given their focus
on increasing access to contraception through coordinated efforts across clinical andcommunity partners by reducing cost and other barriers that inhibit contraceptive choice.
Although many of the early SCAI focused primarily on expanding access to LARC, they have
evolved to implement approaches that expand access to the full range of contraceptive
options using a shared decision-making approach.
SCAI consist of similar implementation approaches, including clinician and staff training
and technical assistance; funding for the provision of low/no-cost contraceptive services,
equipment and supplies; public awareness campaigns; public policy analysis andchampioning; strategic partnerships; and data management and quality assurance.
Evidence suggests that continued attention to organizational and structural factors (e.g.,time, policies and practices, staffing, infrastructure/resources, billing/coding,costs/reimbursements), training, engagement of site leaders, and sustainability of funding
are key to realizing the full potential of SCAI.
SCAI evaluations consist of varied methodologies, data, and analyses. However, one
common evaluation measure was contraceptive use, with a focus on LARC uptake.
Limited data on the impact of SCAI on expanding access to contraceptive care exists in the
published literature. Available evidence demonstrates that SCAI might have positive
impacts on increasing capacity and quality of contraceptive care provision, service
utilization, patient experiences of high-quality care, contraceptive use, and pregnancyrelated outcomes.
An important goal for SCAI is to build sustainable capacity for contraceptive care after
project funding has ended, yet current literature about approaches to SCAI sustainment islimited.
The literature that does exist highlights strategies to secure funding support fromgovernment agencies in addition to philanthropy, extend health center participation andcommunity mobilization activities, and create legislative and policy change.
Research is needed to explore the ability of SCAI to influence access to the full range ofcontraceptive methods, effects on broader health and social outcomes, and how this may
differ across states.
Additional research is needed to document and assess how equity-focused approaches
meet the contraceptive needs and preferences of patients and affect project outcomes.

18

APPENDIX A: ENVIRONMENTAL SCAN SEARCH TERMS AND INCLUSION/EXCLUSIONCRITERIA
•
•
•
•
•
•
•
•
•

Program
Initiative
State
Statewide
Regional
Evaluation
Implementation
Outcomes
Assessment

•
•
•
•
•
•
•

Search Terms
Pregnancy
Unintended pregnancy
Pregnancy prevention
Teen pregnancy
Teen pregnancy prevention
Postpartum
Immediate postpartum

Inclusion Criteria
Journal Article
Project/Initiative Reports
State or Federal agency reports
Reports, presentations, commentary, websites,
meeting notes, discussions regarding SCAI
Studies examining implementation of
coordinated statewide contraceptive accessefforts
Studies examining outcomes of contraceptive
access, utilization, inequities, cost-benefits,
impact on unintended pregnancy
Studies examining evaluation of contraceptive
access, utilization, inequities, cost-benefits,
impact on unintended pregnancy
Studies within the United States
Studies after 2005

• Contraceptive• Contraceptive access• Long-acting reversible
contraceptives• LARC accessExclusion Criteria
Studies outside the U.S.
Studies not evaluating a statewide effort
Studies published prior to 2005

APPENDIX B: OVERVIEW OF STATEWIDE CONTRACEPTIVE ACCESS INITIATIVES
State

Colorado

Initiative Name, Lead Organizationand Status

Colorado Family Planning
Initiative (CFPI)
Lead: Colorado Department of
Public Health and Environment
Status: Complete; 2008-2014

Delaware

Delaware Contraceptive AccessNow (DelCAN)
Lead: State of Delaware andUpstream USA
Status: Complete; 2015-2020

Illinois

Illinois Contraceptive AccessNow (ICAN!)
Lead: AllianceChicago
Status: Ongoing; 2021-2025

Indiana

PATH4YOU
Lead: Indiana University Schoolof Medicine
Status: Ongoing; 2020-

Project Aims

Recent Publications

Increase access to contraception, via:
1. Increased access to quality family-planning services
via Title X network
2. Providing LARCs at no cost
3. Improving community outreach and healtheducation through public awareness campaign
4. Supporting state policy changes to family planning• Romer, S. E., & Kennedy, K. I. (2022). The Colorado
Initiative to Reduce Unintended Pregnancy:
contraceptive access and impact on reproductive
health. American Journal of Public Health, 112(S5),S532-S536.

Reduce unintended pregnancies rate and improveaccess to and delivery of family planning services andcontraceptives (including LARCs) for all women of
reproductive age, via:
1. Implementing state-level policy change
2. Providing trainings and technical assistance toclinical sites
3. Developing statewide public awareness campaign
Create an Illinois where every person can decide
whether, when, and under what circumstances tobecome pregnant and parent, using a three-pronged,
systems-change approach to achieving their goals of:
1. Establishing screening for contraceptive needs anddesires as a routine and essential component ofpreventive and primary care
2. Decreasing the number of people without healthcoverage for contraceptive care
3. Expanding points of access to contraceptive careand education
Provide high-quality, non-coercive, patient-centered,comprehensive contraceptive access to people
throughout the state of Indiana.

• McColl, R. et al. (2023). (2023). Same-day long-acting
reversible contraceptive utilization after a statewide
contraceptive access initiative. American Journal of
Obstetrics and Gynecology, 228(4), 451-e1.

• Yeatman, S., et al. (2022). Expanded Contraceptive
Access Linked To Increase In College Completion
Among Women In Colorado: Study examines the link
between expanded contraceptive access andincreased college completion among women in
Colorado. Health Affairs, 41(12), 1754-1762.

• Yoder, M., & Boudreaux, M. (2023). The effect ofcontraceptive access reform on privately insured
patients: Evidence from Delaware Contraceptive
Access Now. PLoS One, 18(1), e0280588.
• Lassar, M., Tao, K., & Thiede, K. (2022). Advancing
Reproductive Health Equity Through a New
Contraceptive Access Initiative. American Journal of
Public Health, 112(S5), S500-S503.
• Wolff, H., et al. (2024). Reproductive care incommunity health centers: Multi-method evaluationof the Illinois Contraceptive Access Now (ICAN!)
demonstration program. Contraception, 129, 110305.

• Ruggles, M., Wendholt, K., & Bernard, C. (2023).
Indiana Contraceptive Use Metrics through
PATH4YOU Program: Initial Review. Proceedings of
IMPRS, 6(1).

StateIowa

Initiative Name, Lead Organizationand Status

Iowa Initiative to Reduce
Unintended Pregnancies
Lead: The Iowa Initiative
Status: Complete; 2007-2013

Massachusetts

Massachusetts Initiative to
Improve Contraception Services
Lead: Massachusetts Executive
Office of Health and Human
Services
Status: Complete; 2018-2023

Missouri

The Right Time
Lead: Missouri Family HealthCouncil
Status: Ongoing; 2019-2028

Nebraska

Nebraska Sexual andReproductive Health Initiative
Lead: Nebraska Family PlanningSouth Carolina

Status: Ongoing; 2023Choose Well Initiative
Lead: New Morning
Status: Ongoing; 2017-

Project Aims

Recent Publications

Increase access to family planning services, improve
the political climate towards family planning, andreduce unintended pregnancy in the state by
1. Increasing the number of women accessing familyplanning services
2. Increasing adoption of more effective LARCs
3. Increase public funding for family planning
4. Increasing support for family planning services
among general public and elected officials
Promote the availability of effective contraception to
decrease the number of unintended pregnancies andimprove maternal and infant health outcomes acrossMassachusetts, in partnership with Partners inContraceptive Choice and Knowledge (PICCK) and
Upstream USA, by:
1. Addressing training, technical assistance,stakeholder engagement, and quality
improvement
2. Creating a public information campaign similar toa previous national contraceptive training
initiative
Improve reproductive health and rights in Missouri byexpanding the availability of contraceptive services,
improving access to quality information about
contraception, and removing structural barriers tocontraception.

• Quinlan, T. (2018). Assessing the Impact of Two
Statewide Family Planning Initiatives on Birth Rates:
Outcomes from the Colorado Family Planning
Initiative and the Iowa Initiative to Reduce
Unintended Pregnancies (Doctoral dissertation,
University of Colorado).

Provide access to SRH care services and education andserves as a resource and ally for programs and services
across Nebraska.

N/A

Promote equitable access to contraception without
judgment or coercion, with an aim of a 25% reduction
in statewide unintended pregnancy by 2023.

• Beatty, K., et al. (2023). Impact of the Choose Well
Initiative on Contraceptive Access at Federally
Qualified Health Centers in South Carolina: A Midline
Evaluation. American Journal of Public Health,113(11), 1167-1172.

• White, K. O., et al. (2022). Massachusetts Initiative to
Improve Contraception Services: A Tale of Two
Programs. American Journal of Public Health, 112(S5),S478-S483.

• O’Neil, S., & Hoe, E. (2022). Lessons learned from The
Right Time show how to advance reproductive healthduring COVID-19 and beyond. Mathematica.
• O’Neil, S., Hoe, E., & Magee, M. (2022). Progress
toward comprehensive contraceptive access throughthe right time in Missouri. Mathematica.

21

StateUtah

Initiative Name, Lead Organizationand Status

Family Planning Elevated (FPE)

Project Aims

Recent Publications• Hale, N., et al. (2023). Impact of the Choose Well
Contraceptive Access Initiative on Method UseAmong Women Enrolled in South Carolina's
Medicaid Program: A Mid-line Assessment. Women's
Health Issues, 33(6), 626-635.
• Dalessandro, C., Kaiser, J. E., & Sanders, J. N. (2022).
Reproductive autonomy and feelings of control overpregnancy among emerging adult clients in a Utah
(USA) contraceptive initiative study. Sexual &Reproductive Healthcare, 31, 100688.
• Simmons, R. G., et al. (2022). Implementation andMonitoring of the Family Planning ElevatedContraceptive Access Program, Utah, 2018‒2019.
American Journal of Public Health, 112(S5), S528–
S531.

The mission of FPE is equitable access to all methods,
for all communities, at all times, with two main
Lead: University of Utah
objectives:
Department of Obstetrics &1. Improve clinic capacity to provide comprehensive,
Gynecology
person-centered contraceptive care across the
Status: Complete; 2019-2022
state
2. Make no-cost contraceptive care available toindividuals falling in Utah’s contraceptive“coverage gap,” which exists for individuals who
fall between the newly expanded Medicaid
eligibility parameters and 250% of the federal
poverty level
Association of State and Territorial Health Officials (ASTHO) Statewide Contraceptive Access Initiative Learning Communities

In 2014, ASTHO, with support from and participation of multiple federal agencies—including the CDC Division of Reproductive Health, CMS Centers for Medicaid andCHIP Services, and OPA—convened a multi-state Learning Community focused on facilitating access to IPP LARC. The ASTHO IPP LARC Learning Community initially
included 13 states and focused on facilitating cross-state collaboration in implementation of policies and practices to improve access to IPP LARC. The 13 state teams
were comprised of state health officials, payers, clinicians, and health department staff that participated in peer-to-peer learning and state-to-state strategy-sharing
activities to facilitate systems change within hospitals and state Medicaid policies to enable provision of IPP LARC.
In 2016, ASTHO’s Learning Community expanded its focus from IPP LARC to “Increasing Access to Contraception,” including all contraceptive methods, and the numberof participating states increased to 27. The expressed objective of the re-purposed Increasing Access to Contraception Learning Community was to disseminate bestpractices to implement policies and programs that increase access to the full range of contraception options.19 The Learning Community ended in 2018.
For the purposes of the CECA/RISE effort, states that participated in the ASTHO Learning Communities were considered to fit the definition of “statewide contraceptive
access initiatives.” Those states/territories included: Alabama; Alaska; California; Colorado; Commonwealth of the Northern Mariana Islands; Connecticut; Delaware;
Florida; Georgia; Illinois; Indiana; Iowa; Kentucky; Louisiana; Maryland; Massachusetts; Mississippi; Montana; New Mexico; New York; North Carolina; Oklahoma; South
Carolina; Texas; Washington; West Virginia; and Wyoming.

22

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24

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25

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