Policy impacts on contraceptive access in the United States: a scoping review

Abstract

Contraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.

Introduction

Reproductive health politics influence if, when, and how people access health services, factor into reproductive decision-making, and ultimately influence the health and wellbeing of individuals, families, and communities. Throughout history, policy decisions have impacted contraceptive access, in particular. For example, the distribution of contraception was criminalised in 1873 through the Comstock Act (Solinger, 2013), and in Buck v. Bell in 1927, the Supreme Court upheld the legality of forced sterilisation (Price, 2010; Solinger, 2013). Federal and state legislation has also funded abstinence-only sex education, which limits contraceptive access by restricting information about birth control and safe sex (Santelli et al., 2017; Solinger, 2013).

Contraceptive care is made more available and affordable through policies, such as Title X of the Public Health Service Act of 1970 (Title X), which funds community-based health facilities (Dawson, 2020; Solinger, 2013), and the 1972 Medicaid expansion, which funds family planning services and supplies (Ranji et al., 2016). More recently, the Affordable Care Act (ACA) and subsequent amendments established a new healthcare marketplace, requirements for contraceptive care coverage, and expanded dependent and Medicaid coverage (Redhead & Kinzer, 2015; Sonfield, 2011). Many of these provisions remain in place, although the Supreme Court has limited the ACA’s authority by upholding religious and moral exemptions (Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania, 2020) and making Medicaid expansion optional for states (National Federation of Independent Business v. Sebelius, 2012).

Healthcare access framework

By applying Levesque et al.'s (2013) healthcare access framework, the individual and system-level factors that determine contraceptive access can be concretely examined across five dimensions that interact to generate healthcare access: (1) approachability, (2) acceptability, (3) availability and accommodation, (4) affordability, and (5) appropriateness. The first dimension, approachability, refers to community members’ ability to perceive the need for care, which can be supported through targeted education and outreach materials. Acceptability refers to the ability to seek care, which can be dependent on social norms that allow for services rather than creating stigma, embarrassment, fear of judgment, shame, and lack of trust in health care. Availability and accommodation refer to the ability to physically reach care in a timely manner, which is influenced by how far community members live from services, clinic hours of operation, and the ability to access transportation. These issues can produce barriers to care for low-income people and those living in rural areas in particular (Beeson et al., 2014). Affordability refers to the ability to pay for care, which is related to patient income, the cost of services, federal and local clinic funding, and patient access to health insurance. The cost of family planning services and a lack of health insurance are some of the most common barriers that patients cite as reasons they are unable to pay for reproductive healthcare (Zimmerman, 2017). Finally, appropriateness refers to patients’ ability to engage with care, meaning that services must match patient needs and priorities, and health providers must be adequately trained to provide appropriate and unbiased care (Swan, et al., 2020; Beeson et al., 2014; Gomez et al., 2014; Levesque et al., 2013).

Current study

Applying Levesque et al.'s (2013) healthcare access framework to explore the role of US policy in determining contraceptive access, the following research question guided this study: How has federal US policy passed from 2009 to 2019 impacted contraceptive access? To answer this question, empirical research that has examined the impact of recent US federal policy on contraceptive access was identified and summarised. Due to the breadth of the research topic and the focus on describing existing research rather than assessing the quality of the studies, a scoping review methodology was used (Arksey & O’Malley, 2005).

Methods

Using Arksey and O’Malley's (2005) methodological framework for conducting a scoping study, the study’s research question was identified and then selected relevant studies were located. Five searches in PubMed were conducted, one for each category of the guiding healthcare access framework (Levesque et al., 2013). Specific policies previously identified in a systematic grey literature search were considered (see Swan, 2021) and also keywords related to that category of access (e.g., transparency, norms, cost, bias). The exact search terms for each of these searches are available in Appendix 1. This PubMed search was conducted from July 27th to 29th, 2020, retrieving 1562 results, which were supplemented with 21 additional sources identified during the same time frame through a Google Scholar search of each policy and contraceptive access keyword (i.e., “family planning” OR contraceptive OR “birth control”).

After removing duplicates (n = 145) and screening titles and abstracts for relevance and US setting (n = 1275 excluded), a full-text review of the remaining sources (n = 163), excluding those that did not examine policy (n = 41), only included policy changes prior to 2009 (n = 10), were non-empirical (n = 9), only included state-level policy (n = 3), or were not related to contraceptive access (n = 4) was conducted. This left 96 empirical studies (see Fig. 1). Next, the data was charted, recording information about each study that met the inclusion criteria (Arksey & O’Malley, 2005). Finally, the study findings were collated and summarised (Arksey & O’Malley, 2005), organising the literature thematically using Levesque et al.'s (2013) dimensions of healthcare access and according to the policy that each study investigated. The purpose of this scoping review was to provide a broad overview of empirical findings relevant to the influence of policy on contraceptive access. In line with this study's purpose as well as Munn et al.'s (2018) and Arksey and O’Malley's (2005) guidelines on scoping review procedures, an assessment of the methodological limitations of the identified empirical literature was outside of the scope of the current study. These screening and data extraction procedures were conducted by one reviewer, and the methodology and results were reviewed and approved by a panel of four subject and methodological experts.

Fig. 1

Records identified for scoping review

Findings

A summary of the 96 empirical studies about the impact of recent US federal policy on contraceptive access, which were identified through a scoping review, is presented below, organised by policy. For a more in-depth description of the main findings of each study and a mapping of the healthcare access dimensions relevant to each study, see Appendix 2.

Abstinence education

Decades of policy changes have at times promoted abstinence-only sex education and at other times endorsed more comprehensive sex education. For example, after years of increasing funding for abstinence-only sex education, there was a steep decline beginning in 2009 (Fox et al., 2019). In another notable recent change, abstinence-only sex education programs were refunded and rebranded as Sexual Risk Avoidance Education through the Consolidated Appropriations Act of 2012 and the Bipartisan Budget Act of 2018 (Swan, 2021). This review identified two studies related to the impact of policies that fund abstinence-only sex education. These studies indicated that funding abstinence-only sex education programs is not associated with positive outcomes (Fox et al., 2019) and, in fact, can lead to negative outcomes such as increased birth rates among adolescents (Fox et al., 2019; Santelli et al., 2017).

Affordable Care Act

Many studies (n = 53) examined the impact of the ACA (signed into law in 2010) on contraceptive access, finding that the ACA decreased rates of uninsurance among American women (Decker et al., 2018; E. M. Johnston & McMorrow, 2020; Jones & Sonfield, 2016; Kavanaugh et al., 2018; MacCallum-Bridges & Margerison, 2020; Riddell et al., 2018; Willage, 2019) and increased the proportion of patients paying for services with insurance (Arora & Desai, 2016). Although a few studies suggested that the ACA did not lead to changes in preventive service utilisation (Arora & Desai, 2016; Kim & Look, 2017) and out-of-pocket spending (Arora & Desai, 2016), most studies showed increased service utilisation (Dalton et al., 2018; Heisel et al., 2018) and decreased out-of-pocket contraceptive costs (Bearak et al., 2016; Becker, 2018; Becker & Polsky, 2015; Bell et al., 2018; Dalton et al., 2018; Finer et al., 2014; Kim & Look, 2017; Law et al., 2016; Pace et al., 2016a, 2016b; Snyder et al., 2018; Sonfield et al., 2015; Weisman et al., 2019). Furthermore, following ACA implementation, patients with contraceptive co-payments were more likely to be nonadherent than those receiving no-cost contraception (Marshall et al., 2018).

Although one study suggested few changes in contraceptive use patterns (Bearak & Jones, 2017), others showed increased use of contraception (Becker, 2018; Carlin et al., 2016; Pace et al., 2016a; Riddell et al., 2018). Several studies specifically showed that the ACA increased use of more effective contraceptive methods (Becker, 2018; Bullinger & Simon, 2019; Dalton et al., 2018; Heisel et al., 2018; Montgomery et al., 2020; Snyder et al., 2018; Sonfield et al., 2015). Studies also suggested that the ACA was cost-effective for insurers and employers (Burlone et al., 2013; Canestaro et al., 2017) and decreased American women’s risk of unintended pregnancy (August et al., 2016; Burlone et al., 2013; Canestaro et al., 2017; MacCallum-Bridges & Margerison, 2020; Willage, 2019). Furthermore, studies indicated that the ACA increased equity by reducing differences in out-of-pocket spending and contraceptive use based on age, region, and race/ethnicity (Bearak et al., 2016; E. M. Johnston & McMorrow, 2020).

Research specifically investigating the role of optional Medicaid expansion (in effect beginning in 2014) under the ACA indicated that Medicaid expansion increased public insurance coverage (Boudreaux et al., 2019; Darney et al., 2020a, 2020b; Gibbs et al., 2020; Hale et al., 2018; Jones & Sonfield, 2016; Lanese & Oglesby, 2016), decreased uninsurance (Boudreaux et al., 2019; Darney et al., 2020a, 2020b; Dworsky et al., 2012; Early et al., 2018; Hale et al., 2018; Jones & Sonfield, 2016; Lanese & Oglesby, 2016), and increased Medicaid coverage of contraceptives (Veronica et al., 2017). Studies also indicated that Medicaid expansion decreased cost as a barrier to care (E. M. Johnston et al., 2018), increased self-reported contraceptive access (Moniz et al., 2018), increased contraceptive use (Boudreaux et al., 2019; Cher et al., 2019; Darney et al., 2020b; Hale et al., 2018), and decreased publicly funded unintended births (Veronica et al., 2017).

By extending dependent coverage, the ACA also benefited young Americans, decreasing uninsurance rates (Eliason, 2019; Li et al., 2019; Riddell et al., 2018; Willage, 2019), out-of-pocket contraceptive costs (Bearak et al., 2016), and childbearing (Heim et al., 2018) and increasing contraceptive use (Riddell et al., 2018) in this population. Several studies mentioned issues obtaining reimbursement for all contraceptive services covered under the ACA (Zolna et al., 2018) and discussed confidentiality concerns related to newly insured patients (Andrasfay, 2017; Kavanaugh et al., 2018; Masselink et al., 2018; Rogers et al., 2018). At times, patients’ lack of awareness about their coverage under the ACA was also a barrier to contraceptive access (Chuang et al., 2015; Durante & Woodhams, 2017; Nelson et al., 2019; Zolna et al., 2018).

Family planning medicaid waivers

This review identified one study that investigated the impact of a Sect. 1115 Medicaid waiver to expand family planning Medicaid eligibility. From before to after waiver implementation in 2011, this study showed increased use of more highly effective contraceptive methods, including long-acting reversible contraception (LARC), and increased preventive screening utilisation among Medicaid and Title X patients (Dunlop et al., 2016).

Military contraceptive policy changes

A study investigating how military contraceptive policy impacts contraceptive use found that a 2015 Navy policy change expanding contraceptive access during basic training (by increasing education about contraception and providing walk-in contraceptive clinics) increased overall contraceptive use and LARC use specifically. In contrast, a 2016 Marine Corps policy change restricting contraceptive access (by emphasising contraceptive injections for menstrual suppression and reducing the availability of LARC) during basic training decreased contraceptive use and LARC use and increased childbirth rates (Roberts et al., 2020).

Guidelines for quality care

In 2010, the US Centers for Disease Control and Prevention published federal guidelines for contraceptive use entitled the US Medical Eligibility Criteria for Contraceptive Use (updated in 2016; Curtis et al., 2016a). They also published the US Selected Practice Recommendations (published in 2013 and updated in 2016; Curtis et al., 2016b) and the Providing Quality Family Planning Services recommendations (published 2014, updated 2016; Gavin & Pazol, 2016). These documents provide government recommendations for family planning providers, and many healthcare governing agencies and leadership organisations have subsequently endorsed and adopted them. This review identified three studies that investigated the impact of these guidelines, concluding that they have had positive impacts. Title X family planning providers reported that the 2014 Quality Family Planning Services recommendations strengthened client-provider relationships, empowered clients, improved reproductive healthcare access, and linked providers to evidence-based practices (M. Simmons et al., 2016). The Medical Eligibility Criteria for Contraceptive Use guidelines appeared to help align providers’ knowledge and beliefs about contraception with best practices, decreasing false perceptions about intrauterine device (IUD) safety issues (K. B. Simmons et al., 2018; Zapata et al., 2019).

Teen Pregnancy Prevention Program

The Teen Pregnancy Prevention Program was established in 2009 through the Consolidated Appropriations Act of 2010 to provide competitive grant funding for teen pregnancy reduction (Fernandes-Alcantara, 2018). Studies examining the impact of such programs (n = 3) found that, among young residential group home residents, such programs increased reproductive health knowledge, improved attitudes about contraceptive use and healthy sexual behaviors, increased self-efficacy regarding relationships and contraceptive use, and increased intentions to use contraception (Green et al., 2017; Manaseri et al., 2019; Oman et al., 2016).

Title IX of the Education Amendments

Changes in 2011 to Title IX of the Education Amendments (Title IX) required colleges to make efforts to prevent campus sexual violence (Larkin, 2016). A few studies that investigated the impact of these recent Title IX updates (n = 4) indicated that these changes have shed light on and sought to fill gaps in university policies regarding sexual assault and sexual harassment (Bellis et al., 2018; Miller, 2018). These changes are thought to have increased student empowerment to report victimisation experiences (Miller, 2018), potentially increasing access to supportive services, including contraceptive care, following victimisation. However, students have reported barriers to reporting victimisation such as confidentiality concerns (Holland & Cortina, 2017a), and faculty and staff have reported negative unintended consequences such as decreased trust (Holland & Cortina, 2017b; Miller, 2018). Title IX relates to contraceptive access in that supportive services following sexual victimisation often include contraceptive care (Bates, 2022); however, these reviewed studies provide inconclusive evidence as to the impact of the recent Title IX changes on contraceptive access as studies have found conflicting findings regarding how the updated policy may impact help-seeking behaviors after victimisation.

Title X of the Public Health Service Act

Many studies examined the impact of the Title X Family Planning Program (originally established in 1970 and amended in 2016 and 2018) on contraceptive access (n = 25), finding that clinics that received Title X funding were more likely than facilities without Title X funding to provide more comprehensive contraceptive care (Carter et al., 2016; Robbins et al., 2017; Wood et al., 2014) and to provide onsite contraceptive methods (Carter et al., 2016; Centers for Disease Control & Prevention, 2011; de Bocanegra et al., 2014; Jatlaoui et al., 2017; Satterwhite et al., 2019; Wood et al., 2014), including LARCs (Beeson et al., 2014; Bornstein et al., 2018; Carter et al., 2016; de Bocanegra et al., 2014; Jatlaoui et al., 2017; Park et al., 2012; Wood et al., 2014). Despite these instances of improved contraceptive access at Title X facilities, one study indicated that Title X clinics did not differ from other facilities in the accessibility of emergency contraception (French et al., 2018).

Title X facilities were more likely than non-Title X facilities to meet the needs of specific at-risk populations by providing youth-friendly services such as protecting confidentiality and providing youth with contraception (Beeson et al., 2016; Carter et al., 2016; Crain et al., 2020; Kavanaugh et al., 2013; Mead et al., 2015), providing materials and services in Spanish, offering extended clinic hours, and providing outreach to hard-to-reach populations (de Bocanegra et al., 2012). Additionally, Title X providers were less likely than other providers to hold misconceptions about the safety of contraception (Jatlaoui et al., 2017; Shah et al., 2019; K. B. Simmons et al., 2018; Tyler et al., 2012). Although Title X patients were less likely than women nationally to use more effective methods such as LARCs (Fowler et al., 2019), Title X patients were more likely to receive communication about contraception (Liddon et al., 2018), and the presence of a Title X clinic was associated with a decrease in female high school dropout rates (Hicks-Courant & Schwartz, 2016). Studies also indicated that patients reported positive perceptions of Title X clinics, and many patients preferred to receive care at these facilities rather than non-Title X facilities (Frost et al., 2012; Oglesby, 2014).

Some studies suggested barriers to Title X care, indicating that non-Title X facilities were more likely than Title X clinics to have providers trained in IUD insertion (Tyler et al., 2012) and to provide levonorgestrel IUDs, specifically (Centers for Disease Control & Prevention, 2011; Jatlaoui et al., 2017). One study investigated the potential impact of a ban implemented in 2019 which prohibits Title X providers from offering abortion referrals and abortion counselling (formally known as the Protect Life Rule and known by pro-choice advocates as the “domestic gag rule”; Belluck, 2019). This study explored the impact of a similar 2013 policy in Texas, finding that 79% of surveyed family planning organisations had lost their Title X funding by 2015 and reporting a decrease in teen clients attributed by administrators to the loss of confidential services previously guaranteed under Title X (Coleman-Minahan et al., 2019). This study’s findings speak to the potential impact of the federal Title X Protect Life/domestic gag rule.

Violence Against Women Act

Originally established in 1994, the Violence Against Women Act increased penalties for sexual assault perpetration and prohibited survivors from being billed for forensic exams (Tennessee et al., 2017). The Violence Against Women Act was reauthorised in 2013, including incorporation of the Campus Sexual Violence Elimination Act into the Violence Against Women Act. This increased requirements for sexual assault responses at academic institutions. One study exploring how gaps in the Violence Against Women Act, including the 2013 reauthorisation, impacted costs of services for sexual assault survivors found that hospitals billed privately insured survivors for an average of $948 of services not paid under their insurance policy (Tennessee et al., 2017). These costs included prescription medication such as emergency contraception. This study indicates that gaps in the Violence Against Women Act may create affordability barriers to healthcare, including emergency contraception, following sexual assault.

Veterans Access, Choice, and Accountability Act

The Veterans Access, Choice, and Accountability Act of 2014 expanded healthcare options for veterans with specific burdens by allowing them to receive healthcare with choice contracted providers (Gawron et al., 2018). Studies exploring the impact of this Act showed that it increased provider education and patient healthcare access, including reproductive healthcare access, especially in rural areas (Albanese, 2018; Hussey et al., 2016; Mattocks et al., 2017; Stroupe et al., 2019). However, gaps in access remained, including preventive and gynaecological services and in providing respectful care to female veterans (Albanese, 2018; Hussey et al., 2016; Mattocks et al., 2017).

Discussion

Most of the empirical studies identified in this scoping review examined the role of the ACA (n = 53) and Title X (n = 25), showing many benefits of both policies for contraceptive access. Other studies identified in this review reported on the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across all five of Levesque et al.'s (2013) healthcare access dimensions. Figure 2 presents a visual depiction of how the studies in this scoping review relate to the healthcare dimensions, with the majority of studies relating to the affordability dimension (58%).

Fig. 2

Note The case numbers shown along the spectrum display match the case numbers shown in Appendix 2

Specifically, the ACA improved contraceptive access across all five healthcare access dimensions, although most studies described its positive impact on contraceptive affordability, through the contraceptive mandate, increased dependent coverage, and Medicaid expansion. Whereas studies showed improved contraceptive access related to changes to Title X across the healthcare access dimensions, most of these improvements were related to the availability and appropriateness of contraceptive care. Policies impacting veterans and active-duty servicepeople, overall, led to improved contraceptive access, particularly relevant to the availability and appropriateness healthcare access dimensions. New guidelines promoting quality contraceptive care improved the appropriateness of contraceptive care. The Teen Pregnancy Prevention Program improved contraceptive care by impacting the approachability, acceptability, and availability dimensions of healthcare. Changes to Title IX impacted contraceptive access in positive and negative ways, largely by impacting the acceptability dimension.

Despite the many federal policy decisions that have improved contraceptive access in the past decade, this review of empirical literature also showed some decreases in contraceptive access following policy changes. For example, funding for abstinence-only sex education has negatively impacted the approachability and acceptability of contraception. Additionally, while studies showed many benefits of the ACA for contraceptive access, several studies reported decreased approachability and acceptability related to lack of awareness about coverage and confidentiality concerns related to young adult coverage under the ACA’s dependent coverage. Studies also indicated that contraceptive care restrictions for active-duty Marines have limited contraceptive access, and attempts to increase contraceptive access for veterans have left gaps related to the availability and appropriateness of contraceptive care. These issues are identified as opportunities for continued research and for policy and practice intervention.

Although the current study was limited to examining contraceptive access, policy changes related to other aspects of family planning care have also altered access to family planning services. Since true healthcare access means that comprehensive family planning services (ranging from contraceptive and abortion care to fertility and pregnancy services) must be available (J. Johnston & Zacharias, 2017), it is difficult to compartmentalise aspects of family planning care. Exploring the comprehensiveness of family planning care rather than studying services in silos changes study methods and findings. One avenue for future research is the impact of recent policies on abortion access and on the overall comprehensiveness of family planning care. Additionally, future research could build on this study of US federal policy by investigating the role of state-level policies on contraceptive access and on overall family planning access.

There is also a need for more research on policies other than the ACA and Title X, which were by far the most researched policies regarding contraceptive access. Future research is needed to investigate, for example, the impact of Title IX on contraceptive access. The current analysis indicated possible unintended effects of Title IX, including potential confidentiality concerns that limit disclosures and service utilisation and negative impacts on university culture. Continued research could increase understanding of these issues, identify areas for intervention or policy change, and consider how these policy changes have explicitly impacted healthcare utilisation and contraceptive care following victimisation. Such research could include a cost–benefit analysis to help understand the positive and negative impacts of these Title IX regulations on university students as well as faculty and staff.

Policy impacts on marginalised populations

This study also highlights ways that policy has impacted contraceptive access and family planning outcomes for some vulnerable groups. The sources reviewed indicated that age sometimes acted as a barrier to contraceptive access for minors and for young adults included on health insurance as dependents. Policy changes over the past decade have alleviated some of these concerns through legislation that made emergency contraception available to minors over the counter. The ACA and optional state-level Medicaid expansion also helped reduce uninsurance among young adults, including those ageing out of the foster care system. However, the research reviewed in this study also indicated increased barriers to care for young Americans following the ACA, which worsened confidentiality concerns for this group. People living in rural areas have also historically faced barriers to care, although the ACA seems to have reduced regional differences in contraceptive costs and use. Additionally, the Veterans Access, Choice, and Accountability Act has increased healthcare access in rural areas, although it has left gaps related to specific women’s healthcare needs.

A few sources in this review also considered the role of race and ethnicity on contraceptive access. These sources indicated that the ACA decreased racial disparities in contraceptive access and highlighted the importance of Title X in serving racial/ethnic minority patients as well as low-income patients. In light of the recent changes in the Title X program, which have forced many clinics to leave the program in order to continue providing comprehensive care, continued research is needed on the ways that this change may disproportionately impact minority groups and low-income populations. Additionally, the empirical literature reviewed in this study made little to no mention of other populations (e.g., sexual/gender minorities, people with disabilities, people with health conditions such as obesity) who are likely to face disproportionate barriers to contraceptive care based on social, demographic, and health factors. The sources reviewed in this study provide important insights into the impacts of recent policy changes on contraceptive access for certain vulnerable populations, but there is a need for continued research on policy impacts for these and other marginalised groups.

Suggestions for improved policy

This study identified policy needs that could be addressed to improve contraceptive access. Improving contraceptive access begins with increasing the availability of contraceptive information and reducing stigmatising rhetoric by eliminating abstinence-only sex education policies and programs and instead promoting comprehensive sex education (Santelli et al., 2017). Investing in local contraceptive care and providing care options for low-income Americans, through funding streams such as the Community Health Center Fund, would also increase the availability and affordability of care. Such provisions are even more important considering the decreased community clinic options as a result of the Protect Life/domestic gag rule, which led to many clinics withdrawing from the Title X program in order to continue providing comprehensive care. Although the Protect Life/domestic gag rule was revoked in 2021, its impact on contraceptive access over the two years it was in effect is not fully known. Concerns with decreased confidentiality following the ACA could be addressed through policy changes to ensure confidentiality, perhaps using the confidentiality measures included in Title X as an example. Finally, policies aiming to reduce or eliminate healthcare costs following sexual assault could reduce barriers to care and increase access to contraception for survivors.

Practice gaps

This study also identified practice gaps that could be addressed to improve contraceptive access across Levesque et al.'s (2013) dimensions of healthcare access. First, filling gaps at Title X clinics could include increasing the onsite availability of contraceptive methods and provider training in all contraceptive methods and ensuring that when comprehensive contraceptive care cannot be provided onsite, referrals are provided to ensure patient autonomy and continuity of care. Second, there is a need for increased compliance with contraceptive recommendations among family planning providers, indicating an opportunity for increased provider education and adoption of established guidelines. Third, increased outreach efforts could improve contraceptive access by addressing confusion about ACA benefits and helping community members understand their coverage. Finally, increasing the consistency and transparency of contraceptive policies within varying branches of the military and filling gaps left by the Veterans Access, Choice, and Accountability Act, particularly in rural areas, could promote reproductive autonomy and the comprehensiveness of contraceptive care.

Limitations

One limitation of the current study is that it is possible and even likely, that these methods did not identify all relevant federal policies that have recently influenced contraceptive access. By design, the scoping review only captured those studies that included the prescribed keywords. Since policy analysis can vary greatly in methodology and sometimes relevant research does not name pertinent policy changes, some studies were likely excluded from the current review. For example, although many studies have examined various programs funded by the Teen Pregnancy Prevention Program, this scoping review only identified three such studies. Intervention studies that did not explicitly identify the policy origins of their programs’ funding may not have been captured by the current analysis. Future research could more explicitly investigate the role of such interventions, funded through the policies and programs discussed in this review, on contraceptive access and subsequent family planning outcomes. Another limitation is that these screening and data extraction procedures were conducted by one reviewer. This lack of independent screening from multiple reviewers increases the risk of bias. However, a panel of subject and methodological experts provided feedback on and approved the methodology prior to study initiation and reviewed and suggested edits to the study results prior to study completion, increasing the trustworthiness of the findings.

Conclusion

This scoping review has summarised findings regarding the impact of US federal policies passed from 2009 to 2019 on contraceptive access. Two policies in particular, the ACA and Title X, were commonly investigated in the reviewed empirical studies, with findings showing many benefits of both policies for contraceptive access. Studies examining the impact of these policies and several others revealed recent strides in improving contraceptive access across the five dimensions of healthcare access. These studies also identified policy and practice gaps and opportunities for continued research, practice, and policy action that can increase understanding of this topic and improve contraceptive access. In particular, attention to policy impacts for marginalised populations is needed in future research.

Appendices

Appendix 1

Search terms used to identify sources for scoping review.

Search	Terms used
Search 1: Approachability	(“family planning” OR contracept* OR “birth control” OR “reproductive”) AND (knowledge OR health literacy OR information OR awareness) AND (HIPAA OR HITECH OR abstinence education OR “Personal Responsibility Education Program” OR “sexual risk avoidance education” OR “adolescent family life act”)
Search 2: Acceptability	("family planning" OR contracept* OR "birth control" OR "health utilization" OR health OR acceptability OR stigma OR trust OR seek* OR norm OR value OR culture) AND ("Title IX" OR "Campus SaVE Act" OR "Campus Sexual Violence Elimination Act" OR "Violence Against Women Act")
Search 3: Availability and Accommodation	(“family planning” OR contracept* OR “birth control” OR availability OR reach OR transportation OR location OR hour OR appointment) AND (“Community health center fund” OR “Title X” OR “Protect Life Rule” OR “domestic gag rule” OR defund* Planned Parenthood OR Veterans Access, Choice, and Accountability Act)
Search 4: Affordability	(“family planning” OR contracept* OR “birth control” OR “health utilization”) AND (“Affordable Care Act” OR “Women’s Health Amendment” OR “Medicaid expansion” OR “contraceptive mandate” OR “National Defense Authorization Act of 2011” OR “Tricare Young Adult” OR “Association Health Plans” OR “short-term health plan”)
Search 5: Appropriateness	(“family planning” OR contracept* OR “birth control” OR appropriate OR satisfaction OR bias OR engage OR quality OR adequacy) AND (“Teen Pregnancy Prevention Program” OR “Medical Eligibility Criteria for Contraceptive Use” OR “Healthy People 2020” OR “Selected Practice Recommendations” OR “Providing Quality Family Planning Services” OR “domestic gag rule” OR “Title X” OR “VA Mission Act of 2018” OR “Comprehensive Contraceptive Counseling and Access to the Full Range of Methods of Contraception”)

Appendix 2

Empirical literature sources identified for scoping review (N = 96).

Case number. Author, year	Policies	Healthcare access dimensions					Study type	Sample size	Findings
		AR	AC	AV	AF	AP
Fox et al. (2019)	Abstinence-only sex education	X	X				Time-series using nationally representative survey data	865 state-years	Federal block grant funding for abstinence-only sex education from 1998 to 2016 had no effect on overall birth rates among adolescents but increased birth rates among adolescents in conservative states. Funding for adolescent pregnancy prevention and comprehensive sexuality education reduced birth rates among adolescents in conservative states
Santelli et al. (2017)	Abstinence-only sex education	X					Review	Not reported	A review of grey and empirical literature about US abstinence-only sex education policies and programs from 2006 to 2016 showed that these programs are not effective, exclude and violate the rights of adolescents, and reinforce harmful gender stereotypes
Arora and Desai (2016)	ACA—General				X		Pre-post analysis using a nationally representative sample	4397	There was not a significant increase in women’s utilization of reproductive preventive services (birth control prescription, birth control counseling, sterilization counseling, STI services, HIV screening) from before (2011) to after (2013) ACA implementation. After the ACA, respondents paying through insurance increased, but out-of-pocket spending did not decrease
August et al (2016)	ACA—General				X		Simulation using survey data	2.98 million	A simulation study based on data collected in Massachusetts indicated that, by increasing insurance coverage and improving contraceptive access, the ACA was expected to decrease the number of low-income American women at risk of unintended pregnancy from 5.2 million in 2009 to 2.5 million in 2016
Bearak and Jones (2017)	ACA—General				X		Comparison of 2 cross-sections using national survey data	7894 (4,524 in 2012; 3370 in 2015)	There were no significant changes in contraceptive use patterns among sexually active US women before (2012) and after (2015) ACA implementation; however, young women (aged 18 to 24 years) who had not had sex in the last month reported significantly increased oral contraceptive use
Bearak et al (2016)	ACA—General				X		Analysis of administrative data from 41 states	417,221	The number of women with out-of-pocket costs for IUDs decreased from 58% before (2012) to 13% after (2014) ACA implementation. Age and regional differences existed before the ACA but dissolved after ACA implementation, indicating that the ACA reduced inequality in out-of-pocket IUD costs
Becker and Polsky (2015)	ACA—General				X		Analysis of national administrative data	17.6 million month-level observations for 790,895 women	Out-of-pocket costs of oral contraceptives and IUDs dropped by 20% from before (2008) to after (2013) ACA implementation. The average annual out-of-pocket savings per contraceptive user was $255 for oral contraceptives and $248 for IUDs
Becker (2018)	ACA—General				X		Analysis of national administrative data	392,642	Out-of-pocket contraceptive costs decreased dramatically for US women with private health insurance from before (2008) to after (2013) ACA implementation. Insurance claims for any prescription contraceptive method increased by 6.6% as did specific methods including short-term contraceptives prescription emergency contraception (4.8%) and initiation of long-term methods (15.8%)
Bell et al (2018)	ACA—General				X		Retrospective chart review	867	Among women undergoing a first-trimester surgical abortion at a US gynecology practice, the number of privately insured women with no out-of-pocket LARC cost increased from 79% before (2010) to 92% after (2014) ACA implementation. Regardless of insurance type, there was no difference in post-abortal LARC initiation before compared to after the ACA. After ACA implementation, privately insured women with full or partial LARC coverage were more likely to use a post-abortal LARC method compared to privately insured women without LARC coverage
Bullinger and Simon (2019)	ACA—General				X		Analysis of national administrative data	1300 (sales for 50 states × 26 quarters)	Sales of LARCs and injectable contraceptives increased, and sales of pill, ring, and patch contraceptives decreased from before (2008) to after (2014) ACA implementation
Burlone et al. (2013)	ACA—General				X		Decision-analytic model comparing costs and outcomes	Exact number not reported (used data from the American Community Survey)	Using a decision-analytic model and data collected from 2006 to 2011 to compare the costs and outcomes of the ACA contraceptive coverage mandate suggested that this policy is cost-effective for Oregon state insurance providers, saving money and improves outcomes. It increased quality-adjusted life years, prevented an estimated 72 pregnancies per 1000 women over 5 years, and saved $489 per woman enrolled over 5 years
Decker et al. (2018)	ACA—General				X		Analysis of national administrative data	4.8 million clients from ~ 4,000 clinics	Among Title X clinic patients, the percentage of clients without health insurance decreased from 60% before (2005) to 48% after (2015) ACA implementation. The percentage of clients with public health insurance increased from 20 to 35%, and the percentage of clients with private insurance increased from 8 to 15%
Johnston and McMorrow, (2020)	ACA—General				X		Analysis of secondary national survey data	5584 in 2006–2010; 2388 in 2015–2017	Prior to ACA implementation (2006–2010), Black and Hispanic women were less likely than white women to use prescription contraceptives. Uninsurance rates decreased across racial groups from before (2006–2010) to after (2015–2017) ACA implementation, but only Black women experienced a significant increase in prescription contraceptive use
Jones and Sonfield, (2016)	ACA—General				X		Comparison of 2 cross-sections using national survey data	8062 (4,634 in 2012; 3428 in 2015)	Overall rates of uninsurance declined from 19% before (2012) to 12% after (2015) ACA implementation, although Latinas experienced no significant declines. In states that expanded Medicaid, an increase in Medicaid coverage (from 40 to 62%) created a decline in uninsurance among low-income women from 38 to 15%
Kavanaugh et al. (2018)	ACA—General		X		X		Analysis of nationally representative survey data	2911 clients from 43 clinics	In 2016, among Title X clinic patients seeking care under ACA guidelines, most patients (71%) had insurance. Foreign-born patients were less likely to have coverage (46%) than US-born patients. Patients with private insurance were less likely to plan to use their insurance (75%) than those with public insurance (91%), many of whom reported hesitancy to use insurance due to confidentiality concerns
Masselink et al. (2018)	ACA—General		X				Analysis of focus group interviews	54 clinic staff participating in 8 focus groups	After the ACA increased the number of insured patients seeking care at Title X clinics, focus group discussions with Title X clinic staff and state program administrators in 2015 indicated barriers to billing patients’ insurance while maintaining confidentiality such that clinics planned to continue relying on Title X funding to cover services for some insured patients despite ACA health insurance expansions
Riddell et al. (2018)	ACA—General				X		Analysis of secondary national survey data	12,279 in 2006–2010; 5601 in 2011–2013; 5699 in 2013–2015	Young women’s use of prescription birth control changed after ACA implementation, initially increasing from 50% in 2011–2013 to 89% in 2011–2013 and then decreasing to 55% in 2013–2015. Rates of health insurance coverage rose slightly from 77% in 2006–2010 to 80% in 2013–2015
Rogers et al. (2018)	ACA—General		X				Analysis of focus group and individual interviews	153 (62 clients participating in 12 focus groups; 91 key informant interviews)	Individual and focus group interviews held with Title X patients and providers in 10 states revealed confidentiality issues arising from ACA implementation such that centers will likely continue relying on Title X funding even for some insured patients when confidentiality concerns are present
Zolna et al. (2018)	ACA—General			X	X	X	Analysis of nationally representative survey data and individual interviews	535 clinics; 23 interviews	In 2015–2016, Title X clinic administrators reported difficulties obtaining reimbursement for all contraceptive methods covered under the ACA. They reported that staff knowledge about changes related to the ACA was also a barrier to reimbursement and that the ACA caused some of their newly-insured clients to seek care elsewhere, either by choice or because they incorrectly thought they could no longer visit a public clinic
Canestaro et al. (2017)	ACA—Contraceptive mandate				X		Decision model simulation using nationally representative survey data	About 12,000	A decision model using data collected in 2006–2010 simulated costs and outcomes of the ACA contraception mandate, indicating that employers providing no contraceptive coverage increases rates of unintended pregnancies, unintended births, and pregnancy terminations while also increasing total employer costs. Insurance coverage significantly predicted women’s contraceptive use, and the effects of uninsurance were greatest for young unmarried women
Carlin et al. (2016)	ACA—Contraceptive mandate				X		Analysis of national administrative data	29,990	According to data collected from 2008 to 2014 with midwestern women of reproductive age with employer-sponsored insurance, when insurance companies complied with the ACA contraceptive mandate by eliminating out-of-pocket costs for contraceptives, women were more likely to use a prescription contraceptive
Chuang et al. (2015)	ACA—Contraceptive mandate	X			X	X	Analysis of survey data from an ongoing intervention study	987	In 2014, following ACA implementation, privately-insured women of reproductive age in Pennsylvania lacked awareness of their expanded contraceptive benefits, with less than 5% aware that their insurance covered tubal sterilization and 11% aware that it fully covered IUDs
Dalton et al. (2018)	ACA—Contraceptive mandate				X		Analysis of national administrative data	2,172,065	Out-of-pocket costs for women enrolled in employer-based health plans decreased from $24 for preventive care and $29 for LARC insertion before (2008) to roughly $0 after (2015) ACA implementation. The proportion of women with zero cost share for these services decreased from about 30% for both preventive care and LARC insertion in 2008 to 97.1% and 93.9%, respectively, in 2015. When out-of-pocket costs were eliminated through the ACA contraceptive mandate, preventive service and LARC utilization increased
Durante and Woodhams (2017)	ACA—Contraceptive mandate	X			X	X	Analysis of baseline survey data from an ongoing intervention study	316	Among women seeking contraceptive care at an OBGYN clinic in Pennsylvania in 2014, shortly after ACA implementation, most women (52.8%) could not identify any ACA-protected contraceptive coverage stipulations. After a brief educational intervention about ACA provisions, interest in LARCs increased from 37.3% to 44.3%
Finer et al. (2014)	ACA—Contraceptive mandate				X		Analysis of national survey data	889 (sample 1); 343 (sample 2)	More (40%) privately insured women paid zero dollars for oral contraceptives after (2013) ACA implementation than before (2012, 15%)
Heisel et al. (2018)	ACA—Contraceptive mandate				X		Pre-post analysis using nationally representative administrative data	543,499	IUD service utilization increased from 12.5% before (2009) to 13.8% after (2014) ACA implementation. When high out-of-pocket costs were removed through the ACA, IUD insertions increased
Kim and Look, (2017)	ACA—Contraceptive mandate				X		Retrospective study using nationally representative data	24,459 (sample 1); 3,052 (sample 2)	Among insured women of reproductive age, no substantial changes were seen in oral contraceptive utilization from before (2010) to after (2014) ACA implementation. Out-of-pocket costs of prescription oral contraceptives significantly decreased during this time frame for women with private health insurance
Law et al. (2016)	ACA—Contraceptive mandate				X		Analysis of national administrative data	9,320,237 in 2011; 9,599,891 in 2012; 8,348,898 in 2013	Mean out-of-pocket costs of contraceptives for women of reproductive age decreased by about 70% from before (2011) to after (2013) ACA implementation. During this time frame, the average amount spent decreased from $298 to $82 for permanent contraceptives and from $94 to $30 for non-permanent methods ($86 to $26 for oral contraceptives; $83 to $20 for IUDs)
MacCallum-Bridges and Margerison, (2020)	ACA—Contraceptive mandate				X		Analysis of secondary nationally representative survey data	7409	The odds of experiencing unintended pregnancy decreased by 15% from before (2008–2010) to after (2013–2015) ACA implementation. Rates of government-sponsored insurance coverage rose from 17.5% before the ACA to 20.9% after the ACA, and the greatest reduction in unintended pregnancy was observed among these women
Marshall et al. (2018)	ACA—Contraceptive mandate				X		Retrospective cohort study	39,142	Among reproductive-aged women with a new contraceptive prescription at a clinic in California, prior to the ACA (2011–2012) adherence to the contraceptive method was not significantly different among those with and without a copayment; however, after ACA implementation (2013–2014), women with a copayment were more likely than those without to be nonadherent
Montgomery et al. (2020)	ACA—Contraceptive mandate				X		Repeated cross-sectional analysis using nationally representative secondary data	2151	Among young women, there was a significant decrease in short-acting reversible contraception use and a significant increase in LARC use from before (2006–2010) to after (2013–2015) ACA implementation. No significant change in dual-method contraceptive use was found
Mulligan (2015)	ACA—Contraceptive mandate				X		Analysis of nationally representative secondary data	88,076	Prior to the ACA extending mandated contraceptive coverage nationally, state-level mandates enacted in 30 states from 1999 to 2010 increased the likelihood of contraceptive use by 2.1 percentage points and had an insignificant impact on the birth rate
Nelson et al. (2019)	ACA—Contraceptive mandate	X			X	X	Analysis of 2-wave survey data from an intervention study	883	Several years after ACA implementation (2014–2016), very few (7.2%) sexually active women of reproductive age in Pennsylvania who were not trying to get pregnant were aware of no-cost coverage for IUDs. Desire to change contraceptive methods if cost were not a factor predicted new LARC use at a later time point
Pace et al. 2016a)	ACA—Contraceptive mandate				X		Analysis of national administrative data	635,075	Among women with employer-sponsored insurance who were initiating use of the contraceptive pill, out-of-pocket costs significantly decreased from before (2010) to after (2013) ACA implementation, and this decrease was more significant for generic than brand-name oral contraceptives. Higher copays were associated with discontinuation and nonadherence, and both discontinuation and nonadherence decreased significantly following ACA implementation
Pace et al. (2016b)	ACA—Contraceptive mandate				X		Retrospective cohort study using national administrative data	3,794,793	Among reproductive-age women, the proportion of claims with $0 out-of-pocket costs for IUDs and implants, respectively, rose from 36.6% and 9.3% before (2010) to 87.6% and 80.5% after (2013) ACA implementation
Snyder et al. (2018)	ACA—Contraceptive mandate				X		Analysis of nationally representative administrative data	3.88 million in 2006; 4.44 million in 2007; 5.68 million in 2008; 5.86 million in 2009; 6.31 million in 2010; 7.13 million in 2011; 7.32 million in 2012; 6.26 million in 2013; 6.47 million in 2014	Average out-of-pocket contraceptive costs for reproductive-aged women decreased from before (2006–2012) to after (2013–2014) ACA implementation (from $31 to $5 for oral contraceptives, from $13 to $4 for injections, from $60 to $7 for rings, from $78 to $17 for IUDs, from $50 to $24 for implants, from $25 to $8 for patches). New LARC insertions increased significantly
Sonfield et al. (2015)	ACA—Contraceptive mandate				X		Analysis of national longitudinal survey data	1842	Among reproductive-age women with private insurance, the proportion of women with $0 out-of-pocket costs for oral contraceptives rose from 15% before (2012) to 67% after (2014) ACA implementation. Similar changes occurred for injectable (from 27 to 59%), ring (from 20 to 74%), and IUD (45% to 62%) contraceptives
Weisman et al. (2019)	ACA—Contraceptive mandate				X		Analysis of national administrative data	3.88 million in 2006; 4.44 million in 2007; 5.68 million in 2008; 5.86 million in 2009; 6.31 million in 2010; 7.13 million in 2011; 7.32 million in 2012; 6.26 million in 2013; 6.47 million in 2014; 5.00 million in 2015; 4.89 million in 2016	Average out-of-pocket contraceptive costs for reproductive-aged women with private insurance decreased from before (2006–2012) to after (2013–2016) ACA implementation (from $77–118 to $16–28 for IUD; from $52–144 to $19–32 for implants). The percent of women paying $0 for these methods also greatly reduced from 24 and 27% in 2006 to 64% and 90% in 2016, for IUDs and implants, respectively, and LARC use increased significantly
Willage, (2019)	ACA—Contraceptive mandate				X		Analysis of nationally representative secondary survey data	Exact number not reported (used data from the Behavioral Risk Factor Surveillance System)	The ACA’s zero cost-sharing mandate led to a decrease in births but increased STIs related to a decline in condom use. The ACA dependent coverage mandate had a protective effect, increasing rates of insurance and decreasing rates of STIs among young adults
Andrasfay, (2017)	ACA—dependent coverage		X				Analysis of nationally representative secondary survey data	2108	Despite the potential for confidentiality breaches following ACA expansion of dependent insurance coverage for young adults, in 2015, young adults insured as dependents had similar reproductive health service utilization to that of their policyholder peers
Eliason (2019)	ACA—dependent coverage				X		Difference-in-difference analysis using nationally representative secondary survey data	7649	The ACA dependent coverage provision was associated with a significant decrease in the probability of lacking health insurance from before (2006–2009) to after (2011–2013) implementation. It did not appear to have an impact on sexual and reproductive health service utilization overall. Results indicated differences in how the ACA impacted these outcomes based on race, with increases in service utilization observed for Hispanic women and rates of insurance coverage increasing for Hispanic women and non-Hispanic white women but not for Black women
Heim et al. (2018)	ACA—dependent coverage				X		Analysis of national administrative data	401,922	Among young adults aged 24–29, childbearing decreased by about 0.4 percentage points from before (2008–2009) to after (2011–2013) implementation of the ACA dependent coverage provision
Li et al. (2019)	ACA—dependent coverage				X		Difference-in-difference analysis using nationally representative secondary survey data	44,960	From 2009 to 2013, among young women with a recent live birth, the ACA dependent coverage provision decreased uninsurance by 4.7 percentage points, increased private insurance coverage by 5.4 percentage points, increased private insurance coverage in the month before pregnancy by 5.9 percentage points, decreased Medicaid coverage during pregnancy by 5.9 percentage points, and increased receipt of timely prenatal care by 3.6 percentage points
Boudreaux et al. (2019)	ACA—Medicaid expansion				X		Difference-in-difference analysis of national administrative data	230 state-years	From 2012 to 2016, among Title X clinic patients, the ACA’s Medicaid expansion was associated with increases in Medicaid coverage by 9.9 percentage points and decreases in uninsurance by 10.0 percentage points. Results also suggested associations between expansion and increased LARC used
Cher et al. (2019)	ACA—Medicaid expansion				X		Difference-in-difference analysis of national administrative data	Exact number not reported (used Medicaid State Drug Utilization Data)	In states that expanded Medicaid, overall prescription use (6.9% increase) and prescription contraceptive use (2.4% increase) per enrollee were higher after (2014–2016) ACA Medicaid expansion than before (2010–2013)
Darney et al. (2020a),	ACA—Medicaid expansion				X		Analysis of administrative data from 11 states	162,666	In 2013–2014, uninsured contraceptive visits at safety-net clinics decreased following ACA Medicaid expansion in both expansion and non-expansion states, although overall uninsured visits were lower in expansion states
Darney et al. (2020b)	ACA—Medicaid expansion				X		Retrospective cross-sectional study using administrative data from 24 states	545,540	In 2013–2016, at community health centers in 24 states, ACA Medicaid expansion was associated with increased LARC use among reproductive-aged women, with those in expansion states 1.2 percentage points more likely to use LARCs than those in non-expansion states
Dworsky et al. (2012)	ACA—Medicaid expansion				X		Analysis of secondary survey data	378	Using data collected in the Midwest from 2002 to 2009, Medicaid expansion similar to that implemented by the ACA increased Medicaid eligibility for former foster youth and for low-income individuals and decreased uninsurance for young women aging out of foster care. Projections predicted similar outcomes under the ACA’s Medicaid expansion
Early et al. (2018)	ACA—Medicaid expansion				X		Analysis of secondary survey data	4567	Among low-income Californian women of reproductive age, rates of uninsurance decreased significantly from 29% before (2013) to 11% after (2014–2016) ACA Medicaid expansion while rates of Medicaid coverage increased from 37 to 67%. Despite these changes in insurance coverage, health utilization remained unchanged
Gibbs et al. (2020)	ACA—Medicaid expansion				X		Analysis of administrative data	83,719 pre-ACA; 103,225 post-ACA non-expansion; 73,945 post-ACA expansion	Medicaid enrollment and claims data for reproductive-aged women in Oregon indicated increased Medicaid coverage and Medicaid financing of preventive reproductive services for newly-enrolled low-income women from before (2011–2013) to after (2014–2016) ACA Medicaid expansion
Hale et al. (2018)	ACA—Medicaid expansion			X	X	X	Repeated cross-sectional study using national administrative data	Exact number not reported (state-level characteristic reported for all 50 states and Washington, D.C.)	Among Title X clients, there were national increases in the proportion of women with Medicaid or private insurance, increases of women with Medicaid, and decreases in women with no insurance from before (2012) to after (2016) ACA Medicaid expansion. ACA Medicaid expansion was less common (46.2%) in states with the highest need (where there were greater numbers of low-income reproductive-aged women trying to avoid pregnancy) compared with those with the lowest need (91.7%). Nationally, LARC use among Title X patients increased from 9.1% in 2012 to 16.2% in 2016. LARC use increased in Medicaid expansion states from 10.0% in 2012 to 17.9% in 2016 and in non-Medicaid expansion states from 7.70% to 13.6%
Johnston et al. (2018)	ACA—Medicaid expansion				X		Difference-in-difference analysis of national administrative data	24,955	Among low-income women of reproductive age, uninsurance decreased by 13.2 percentage points, and the likelihood of experiencing cost as a barrier to care decreased by 3.8 percentage points from before (2012) to after (2015) ACA Medicaid expansion. Women without children experienced a 13.3 percentage point increase in the likelihood of having a personal doctor. Post-ACA decreases in uninsurance were greater in states with lower pre-ACA Medicaid thresholds (19.4 percentage points) and in states without pre-ACA Medicaid family planning waivers (17.6 percentage points)
Lanese and Oglesby (2016)	ACA—Medicaid expansion			X	X		Analysis of national administrative data	Exact number not reported (used data from Family Planning Annual Reports)	According to publicly available national data, all states’ Title X clinics lost revenue from before (2013) to after (2014) ACA Medicaid expansion implementation, although expansion states fared better than non-expansion states. Nationally and on a state-level, the number of Title X family planning users decreased from 2013 to 2014, and the number of these users with public and private health insurance increased
Moniz et al. (2018)	ACA—Medicaid expansion				X		Analysis of survey data	1166 (weighted to 113,565)	In 2016, reproductive-aged women enrolled in Michigan’s post-ACA Medicaid expansion waiver program reported increased access to birth control and family planning services. Younger women, women without health insurance in the year preceding Medicaid expansion, and women with a recent visit to a primary care clinician were more likely to report increased access
Veronica et al. (2017)	ACA—Medicaid expansion				X		Content analysis of publicly-available information regarding Medicaid state coverage	9 states	In 9 states (California, Colorado, Georgia, Illinois, Missouri, New York, Pennsylvania, Texas, and DC) in 2015, 6 of which expanded Medicaid under the ACA, content analysis indicated that all 9 states’ Medicaid programs covered some aspects of LARC, but only 1 state’s program (California) incorporated all aspects from counseling and insertion to removal and follow-up. States with more comprehensive coverage for LARC had lower percentages of publicly funded unintended births
Dunlop et al. (2016)	Medicaid waivers			X	X		Analysis of administrative data	172,525	There was increased use of more highly effective contraceptive methods, including LARCs, among Medicaid and Title X patients and increased preventive screening utilization among Title X patients from before (2009) to after (2013) implementation of the Georgia Sect. 1115 Medicaid family planning waiver, which expanded eligibility for family planning Medicaid beginning in 2011
Roberts et al. (2020)	Military policy			X			Analysis of administrative data	70,852	A 2015 Navy policy change expanding contraceptive access during basic training (by increasing education about contraception and providing walk-in contraceptive clinics), increased contraceptive use from 33.1% before the change (2013) to 39.2% after the change (2016) and increased LARC use from 11.0% to 22.7% but was not associated with a decline in childbirth rates relative to the change among women in the Army and Air Force. A 2016 Marine Corps policy change restricting contraceptive access during basic training (by emphasizing contraceptive injections for menstrual suppression and reducing the availability of LARC) decreased contraceptive use from 19.6 to 24.4%, decreased LARC use from 14.6 to 7.3%, and increased childbirth rates from 8.0% to 9.6%
Simmons et al. (2016)	Providing Quality Family Planning Services (QFP)					X	Analysis of interviews	16	Interviews with Title X family planning providers in Indiana and Missouri revealed that providers viewed the 2014 QFP recommendations as an improvement over previous guidelines, stating that they strengthened client-provider relationships, empowered clients, improved reproductive healthcare access, and linked providers to evidence-based practices. Barriers to implementation included providers’ negative values and beliefs about client-centered counseling and the advantages of the recommendations, misinterpretation, and billing issues
Green et al. (2017)	Teen Pregnancy Prevention Program	X	X	X			Cluster randomized controlled trial	1036	From 2012 to 2014, among youth at residential group homes in three states (California, Maryland, Oklahoma), the teen pregnancy prevention program Power Through Choices improved participants’ knowledge about anatomy and fertility, HIV and STIs, and methods of protection; attitudes about contraceptive use; self-efficacy regarding communication with a partner, plans for protected sex, and obtaining birth control; and intentions to use birth control
Manaseri et al. (2019)	Teen Pregnancy Prevention Program	X					Cluster randomized controlled trial	1783	From 2011 to 2013, among middle schoolers in Hawai’i, the teen pregnancy prevention program Pono Choices increased students’ knowledge of medically accurate pregnancy and STI information, improved their attitudes toward healthy sexual behaviors, increased their skills in managing relationships and obtaining and using contraception, and increased their intentions to abstain from sex or engage in safe sex. However, it did not impact participants’ initiation of sexual activity
Oman et al. (2016)	Teen Pregnancy Prevention Program	X	X	X			Cluster randomized controlled trial	1037	From 2012 to 2014, among youth at residential group homes in three states (California, Maryland, Oklahoma), the teen pregnancy prevention program Power Through Choices improved participants’ knowledge about anatomy and fertility, HIV and STIs, and methods of protection; attitudes about contraceptive use; self-efficacy regarding communication with a partner, plans for protected sex, and obtaining birth control; and intentions to use birth control
Holland and Cortina (2017a)	Title IX of the Education Amendments (Title IX)	X	X				Analysis of survey data	305	Resident assistants (who are required to report sexual assault disclosures under many universities’ new Title IX policies) at a midwestern university, reported that resident assistants’ knowledge of reporting procedures, trust in supports, and perceptions of mandatory reporting policy impact their likelihood of reporting sexual assault disclosures
Holland and Cortina (2017b)	Title IX	X	X	X		X	Analysis of survey data	840	In 2015, at a large Midwestern university, only 5.6% of college students who experienced sexual assault disclosed the assault to formal campus supports (Title IX Office, Sexual Assault Center, housing staff). They indicated that logistical issues such as time and knowledge, responses that make it seem unacceptable to use campus supports, judgments about the appropriateness of supports, and alternative methods of coping prevented them from using formal campus supports. Confidentiality was also a concern, with mandated reporting preventing students from discussing their assault with formal supports
Miller (2018)	Title IX		X				Analysis of interviews	19	Interviews with university staff and administrators revealed perceived positive and negative impacts of Title IX, indicating that there had been a lack of clear guidance, shifts in institutional structure and staffing, legalization of the student conduct processes, staff feeling on trial, greater public scrutiny, changes in relationships with students, personal impacts, and shifts in career ambitions. The 2011 Dear Colleague letter and subsequent changes created an environment where students felt empowered to report assaults and increased survivor access to resources and services; however, participants indicated that these policy changes negatively shifted student–teacher relationships, increased administrator stress, and created an environment of mistrust
Bellis et al. (2018)	Title IX		X				Analysis of survey data; Content analysis of school reports and policies	24 schools	Changes in federal Title IX regulations related to the 2011 Dear Colleague letter led to a reduction in Georgia colleges and universities deemed “Clery compliant” from 70% in 2013 to 12% in 2014. These schools varied greatly in how they responded to sexual violence. The lowest 2014 compliance category was “procedures following a report” (54.2%)
Beeson et al. (2014)	Title X Family Planning Program (Title X)- General			X		X	Analysis of survey data	423 clinics	In 2013, most (56% for levonorgestrel IUD; 52% for copper IUD) Federally Qualified Health Centers (FQHCs) offered on-site IUDs but only 36% offered on-site contraceptive implants. FQHCs receiving Title X funding were more likely to provide on-site access to LARCs (79% for levonorgestrel IUD, 80% for copper IUD, 56% for implant) than FQHCs not receiving this funding (55% for levonorgestrel IUD, 50% for copper IUD, 35% for implants)
Beeson et al. (2016)	Title X—General		X				Analysis of survey data and case studies	423 clinics (survey); 5 individual interviews	In 2011, most health centers engaged in efforts, such as providing written or verbal information (81%) and limiting access to medical records (84%), to protect adolescents’ rights to confidential care. Fewer health centers maintained separate records for family planning (10%), used a security block on medical records (43%), or used separate contact information for communication regarding family planning (50%). Health centers that received Title X funding scored higher on measures of confidentiality efforts than facilities that did not receive such funding
Bornstein et al. (2018)	Title X—General			X		X	Analysis of nationally representative data	1615	In 2013–2014, 64% of publicly funded health centers offering family planning services reported having staff trained in all three LARC types (hormonal IUD, copper IUD, implant), and 52% offered any IUD onsite. Title X-funded health centers had greater odds than non-Title-X-funded health centers of offering IUDs and implants onsite
Carter et al. (2016)	Title X—General		X	X		X	Analysis of nationally representative data	1615	In 2013–2014, publicly-funded health centers reported frequently providing contraceptive services (89%) for women in the past three months, with 63% providing hormonal IUDs onsite and 48% providing implants onsite. Only 40% included all five recommended contraceptive counseling practices in written protocols. Most centers reported providing youth-friendly services by promoting confidential services (83%). Health centers that received Title X funding were more likely than those not receiving such funding to provide comprehensive family planning services, contraceptive methods onsite, written protocol on contraceptive counseling, and youth-friendly services, including promoting confidentiality
Centers for Disease Control and Prevention (2011)	Title X—General			X		X	Analysis of national survey data	2003	In 2009–2010, about half of sampled Title X clinic providers and office-based physicians provided onsite IUDs and about one-third provided onsite implants. Compared to office-based physicians, a higher proportion of Title X clinic providers reported on-site availability of all contraceptive methods (copper IUD, implant, injectable, oral contraceptives, patch, ring, and condoms) except levonorgestrel IUDs
Crain et al. (2020)	Title X—General			X		X	Retrospective chart review	1 academic practice and 11 Title X clinics	In West Virginia, LARC use increased for adolescent patients from 2010 to 2016. Title X providers were 2.9 and 2.8 times more likely to provide implants to adolescent patients compared to general practice and pediatric and adolescent gynecologists at non-Title X practices, respectively
de Bocanegra et al. (2012)	Title X—General	X		X		X	Analysis of survey data	1072	In 2010, among clinics participating in California’s state family planning program, Title X-funded clinics were more likely than non-Title-X-funded clinics to have Spanish-speaking staff and Spanish-language signs, to offer extended clinic hours, to provide outreach to at least three vulnerable or hard-to-reach populations (e.g., adolescents, LGBT people, refugees), and to use advanced technologies (e.g., electronic prescriptions, online appointment scheduling, text/email reminders)
de Bocanegra et al. (2014)	Title X—General			X		X	Analysis of survey data	1072	In 2010, among providers at clinics participating in California’s state family planning program, Title X-funded providers were more likely than non-Title-X-funded providers to offer onsite IUDs, contraceptive implants, vasectomies, and fertility awareness methods
Fowler et al. (2019)	Title X—General			X		X	Analysis of nationally representative secondary survey data	Family Planning Annual Report samples 2006–2007: 8.2 million, 2008–2010: 12.4 million, 2011–2013: 11.3 million, 2014–2016: 9.2 million; National Survey of Family Growth samples 2006–2008: 1052, 2008–2010: 1213, 2011–2013: 1109, 2013–2015: 1037	Among Title X clients at risk of unintended pregnancy during 2006–2016, LARC use increased from 3 to 14% and use of moderately effective methods decreased from 64 to 54%. Use of sterilization, less effective methods, and no method changed insignificantly. In 2014–2016, similar rates (90%) of Title X clients and women nationally used any contraceptive method, and similar percentages used implants (~ 5%) and pills (32–34%). Title X clients were less likely than women nationally to use no contraceptive method (7% vs. 10%), sterilization (2% vs. 5%), IUDs (9% vs. 13%), and withdrawal (2% vs. 6%). More Title X clients than women nationally used hormonal methods other than LARCs and pills (22% vs. 14%) and used male condoms (17% vs. 12%)
French et al. (2018)	Title X—General			X		X	Analysis of data created using secret shopper calling	40 clinics	In 2017, among Kansas City clinics listed as emergency contraception providers, 32% were willing to prescribe ulipristal acetate over the phone to existing patients, and 38% required an appointment with a provider. Few clinics (8%) offered the copper IUD as emergency contraception. Title X clinic status did not predict any of these provisions
Frost et al. (2012)	Title X—General		X	X	X	X	Analysis of nationally representative survey data	1800	In 2011–2012, among family planning clinic patients in 13 states, many of which are funded through the Title X program, 59% of had visited another provider in the past year but chose the family planning clinic for contraceptive care, and 41% relied on the clinic as their only recent source of health care. Over 80% reported their reasons for choosing a specialized family planning clinic as respectful staff, confidential care, free or low-cost services, and staff who are knowledgeable about women’s health
Hicks-Courant and Schwartz (2016)	Title X—General			X			Retrospective cross-sectional study using secondary national survey data	284,910	In 2012–2013, among young women aged 16 to 22 years, the presence of a Title X clinic (having one in the Public Use Microdata Area of residence of about 100,000 residents) was associated with a decrease in female high school dropout rates (from 4.79% to 5.07%)
Jatlaoui et al. (2017)	Title X—General			X		X	Analysis of survey data	1958	In 2009–2010, shortly before the release of USMEC contraception guidelines, many healthcare providers had misconceptions about the safety of oral contraceptives (31%), DMPA (24%), the copper IUD (18%), and levonorgestrel IUDs (16%) for women who were obese. Title X providers were less likely to hold these misconceptions and to provide onsite levonorgestrel IUDs (46% vs. 55%) but were more likely to provide onsite oral contraceptives (92% vs. 40%), DMPA (97% vs. 61%), and copper IUDs (59% vs. 52%) than office-based providers
Kavanaugh et al. (2013)	Title X—General	X	X	X			Analysis of nationally representative survey data	1196	As of 2011, publicly funded family planning facilities varied in their ability to provide youth-friendly contraceptive services, with 67% not requiring appointments for method refills, 64% having flexible hours, 70% providing outreach or education to young people, and most taking steps to ensure confidentiality. These practices were more common at Planned Parenthood, Title X, and reproductive health facilities than at other facilities
Liddon et al. (2018)	Title X—General			X		X	Analysis of nationally representative secondary survey data	2368	From 2011 to 2015, among sexually active females aged 15 to 24 years, 65.0% reported receiving provider communication about condoms and 64.0%-66.8% about birth control. Title X funded clinic patients were more likely to receive communication about condoms and birth control than patients at non-Title X public clinics and at private facilities. Non-Title X public clinic patients were more likely to receive communication about emergency contraception than Title X public clinics and private facilities
Mead et al. (2015)	Title X—General	X		X	X	X	Analysis of national survey data and case studies	423 clinic surveys; interviews at 6 case study sites	In 2011, Title X-funded clinics provided more family planning services tailored to adolescents than non-Title X-funded clinics. Location in a state with a favorable state policy environment was associated with more family planning services tailored to adolescents
Oglesby, (2014)	Title X—General		X	X	X	X	Analysis of survey data	696	In 2012, patients at 8 Title X clinics in Ohio stated very positive perceptions of Title X funded clinics, reporting that they “always” go there for birth control, STD/HIV testing, and pregnancy testing and that these clinics were their regular source of health care
Park et al. (2012)	Title X—General			X		X	Analysis of administrative data	1786	In 2009, Title X clinic providers were more likely to provide onsite LARC services than non-Title X public and private providers
Robbins et al. (2017)	Title X—General					X	Analysis of nationally representative survey data	1039 linked provider-administrator pairs	In 2013–2014, administrators and providers at publicly-funded health centers indicated that centers receiving Title X funding were less likely to have reproductive life plan assessment protocols than those not receiving Title X funding. When such a protocol was in place, patients received more frequent assessment, which was then associated with more frequent preconception care
Satterwhite et al. (2019)	Title X—General			X		X	Analysis of survey data	237	In four Midwest states in 2017–2018, health departments that received Title X funds were more likely to provide any prescription contraception (85.1%) than those not receiving Title X funds (14.2%)
Shah et al. (2019)	Title X—General					X	Analysis of nationally representative survey data	2060	Providers working in clinics with Title X funding were more likely to answer correctly regarding the effectiveness of combined oral contraceptives for patients with malabsorptive bariatric procedures than those in clinics without Title X funding, where providers were more likely to be uncertain about the effectiveness of this method with these patients
Simmons et al. (2018)	Title X—General; US Medical Eligibility Criteria for Contraceptive Use (USMEC)					X	Analysis of nationally representative survey data	1998	In 2013–2014, providers at clinics with Title X funding were less likely to incorrectly believe that IUDs were unsafe for women with HIV than those at clinics without Title X funding. Clinics that used the USMEC for clinical guidelines were less likely to hold this incorrect belief about IUDs than those who did not use the USMEC. Title X-funded centers were more likely to use the USMEC than other public centers and office-based physicians
Tyler et al. (2012)	Title X—General					X	Analysis of nationally representative survey data	1323	In 2009–2010, Title X providers were more likely to identify as female (95.0%) than office-based physicians (49.5%), and Title X providers were more likely to serve racial/ethnic minority patients, non-English-speaking patients, patients with Medicaid, and teenage patients. Office-based providers were more likely to be trained in IUD insertion and to have misconceptions about the safety of IUDs for nulliparous women than Title X clinic providers
Wood et al. (2014)	Title X—General			X	X	X	Analysis of national survey data	423	Among FQHCs in 2011, Title X-funded sites were more likely to provide all contraceptive methods (oral contraceptives, injectables, patch/ring, emergency contraception, barrier methods, IUDs, and implants) than sites without Title X funding
Coleman-Minahan et al. (2019)	Title X—Domestic gag rule		X	X		X	Analysis of interviews	47 organizations	In Texas, where new Title X regulations similar to the domestic gag rule were implemented in 2013, 79% of surveyed family planning organizations that previously received Title X funding had lost that funding by 2015. Administrators at these organizations reported a decrease in teen clients which they attributed to the loss of confidential services previously guaranteed under Title X
Zapata et al. (2019)	US Medical Eligibility Criteria for Contraceptive Use (USMEC)					X	Comparison of 2 cross-sections using national survey data	3445	Office-based physicians and Title X clinic providers reported knowledge and beliefs about contraceptive methods that more accurately aligned with the USMEC guidelines after (2013–2014) these guidelines were released than before (2009–2010). Their perceptions of the safety of IUDs for adolescents and women with HIV and DMPA for those who are obese or have a history of bariatric surgery, all of which are classified as safe under the USMEC, also increased
Tennessee et al. (2017)	Violence Against Women Act		X		X		Analysis of insurance providers’ payment patterns	1355 incident events	Gaps in the Violence Against Women Act through the 2013 reauthorization causes hospitals to bill sexual assault survivors directly for services not paid under their insurance policy, costing privately insured patients an average of $948. Amending this act could prevent costs incurred because of sexual assault from being passed on to the victim
Albanese et al. (2018)	Veterans Access, Choice, and Accountability Act			X		X	Analysis of administrative data	Not reported	Three years after the VCA was enacted in 2014, medical residency programs had expanded to more rural and underserved locations. Access to specialty services, such as preventive medicine and obstetrics and gynecology, remains limited
Hussey et al. (2016)	Veterans Access, Choice, and Accountability Act			X		X	Analysis of key informant interviews and survey data	Not reported	One year after the 2014 implementation of the VCA, VA medical facility leaders reported that VA healthcare was good or better on most measures compared with other health systems. Access to specialty care, such as cardiology and oncology services, was limited, especially in some geographic areas, and wait times varied across facilities. Although access to basic reproductive health services appeared to have increased, there remained a need for providers to help female veterans feel respected during health encounters
Mattocks et al. (2017)	Veterans Access, Choice, and Accountability Act			X			Analysis of interviews	43	In 2015, Veterans Health Administration staff and providers indicated that the VCA was implemented too rapidly with inadequate preparation and development of community provider networks to meet veterans’ care needs. Participants reported limited availability of specialty providers, such as gynecological care, in rural locations
Stroupe et al. (2019)	Veterans Access, Choice, and Accountability Act			X		X	Analysis of survey data, administrative data, and interviews	4521 surveys; 60 interviews	In 2017, among VA patients in the Midwest, women patients, patients living further from VA facilities, and patients with worse health status were more likely to use or intend to use the Veterans Choice Program, which was developed as a result of the VCA. Many women veterans reported using the program for gender-specific services not available at VA health centers

1. AR = Approachability, AC = Acceptability, AV = Availability/Accommodation, AF = Affordability, AP = Appropriateness.