Urban-rural differences in family planning services for women in Midwest and near-Western states: A survey of Title X providers
Abortion, Contraception
Awarded 2011
Complex Family Planning Fellowship Research
Katherine Damm, MD
The University of Chicago

Background: There is a paucity of research on access to and provision of family planning services in the rural United States, and specifically little attention has been paid to rural adolescents and their family planning needs. Rural women face general and reproductive health care disparities, which have previously been described. Most available family planning data were published prior to more recent advancements in contraception and abortion. By analyzing urban-rural differences related to family planning in the understudied center of our country, we hope to highlight areas for clinical improvement, contribute to the literature on rural health care and disparities, and provide the methodological groundwork for additional nationwide studies.
Purpose: The goal of this study was to identify barriers and facilitators – at both the clinic and provider levels – to providing long-acting reversible contraception (LARC), emergency contraception (EC), and abortion referrals to rural women, including adolescents, compared to their urban counterparts. We focused on Title X clinics as front-line providers of reproductive health care to women in both rural and
urban geographies. This research was further centered on Midwestern and Near-Western states (HHS Regions V, VII, and VIII), which contain clinically underserved areas, both urban and rural, that are not frequently studied.
Methodology: With IRB approval, we conducted key informant interviews with Title X regional program consultants and clinic managers in rural and urban clinics to gain an understanding of barriers and facilitators of reproductive health care. Participants received a $50 gift card for completing the interview. This information was used to develop a 38-question survey, which was pre-tested with experts from the field for face validity and subsequently mailed to managers of 813 Title X clinics in Regions V, VII, and VIII. Multiple contact attempts were made to boost the response rate in the following sequence: (1) a postcard, (2) a letter with option to complete the survey online, (3) an e-mail, (4) a phone call, and (5) a last-ditch e-mail reminder. As an incentive, survey respondents were offered the option of entering their clinic in a raffle for one of five $500 gift cards to Amazon.com. Primary outcomes – LARC, EC, and abortion referral access – will be modeled separately in multivariable regression models to assess the impact of geography (rural vs. urban) along with other covariates.
Findings: Four key informant interviews were completed. Identified barriers include: rural location of clinics, patient transportation, patient knowledge, cost of contraceptives, decrease in available Title X funding, and clinician training and availability. Facilitators were also described: additional funding sources, extended clinic hours, and community outreach programs. The survey response rate was 76%. Analysis of survey data is currently in progress.