The impact of publicly financed family planning services on pregnancies, births and costs: a critical review of the peer-reviewed literature

Introduction Low-income women in the United States obtain access to family planning services in large part through publicly subsidised federal, state and local programmes. Public support for publicly funded family planning care is based on the belief that these programmes reduce unintended pregnancy, promote better birth outcomes and save governments money. There is, therefore, a need to assess the results from and quality of existing research in this area. This article discusses the impact of publicly financed family planning services on pregnancies, births and costs. Materials and methods This article reviews 11 published evaluations of publicly financed family planning services and its impact on pregnancies, births and costs for the period 1990–2013. Relevant studies were identified through a search of PubMed and SCOPUS databases and the strength of their methodology was assessed using the US Preventive Services Task Force quality rating criteria. Results All reviewed articles received a quality rating of ‘fair’ but varied on a number of different dimensions, including their methodology, data sources, time frame, outcomes of interest and scope, preventing direct The impact of publicly financed family planning services on pregnancies, births and costs: a critical review of the peer-reviewed literature MT Gerstein*, AR Markus* comparisons across studies. Results from reviewed analysis do, however, suggest that publicly funded family planning services avert a significant proportion of unintended pregnancies, improve birth outcomes and reduce governmental costs. Conclusion The reviewed literature demonstrates that publicly financed family planning care promotes control over childbearing decisions and improved birth outcomes, while saving local, state and federal governments money. However, this review also identified several important research gaps and flaws in the existing evidence base, particularly in the generalisability of results and narrow set of measures used to estimate impact. We suggest several ways to expand the field of available research by leveraging opportunities afforded through state Medicaid reform legislation and Medicaid expansions under the Affordable Care Act. Introduction Low-income women in the United States rely, in large part, on publicly financed family planning services to help achieve their childbearing goals and prevent unintended pregnancy. In 2010, nearly nine million U.S. women received publicly subsidised family planning. Of these nine million, close to seven million sought services at publicly funded clinics, accounting for one of every four women in the U.S. who accessed family planning care1. Public funding for these services comes from a number of federal, state and local sources. Since the 1970s, the Title X federal grant, the only federal programme devoted to the provision of comprehensive family planning to low-income individuals and/or uninsured people, has been a key source of this care2. In recent decades, Medicaid coverage for family planning has too grown substantially, overtaking Title X to become the largest single public funding source for these services. In 2010, more than two million women received Medicaid-reimbursed contraceptive services from private physicians1. In 2010, public expenditures for family planning services totalled $2.37 billion; Medicaid accounted for 75% of these total expenditures, state appropriations for 12% and Title X for 10%3. Over four decades of public support for the provision of family planning care to low-income and/or uninsured women has been based, in large part, on the belief that these expenditures increase access to and utilisation of contraceptives and by doing so, reduce unintended pregnancy, promote better birth outcomes and ultimately save local, state and federal governments money. This article presents a critical review of the evidence in this area through an examination of the available literature on the impact of publicly financed family planning services on pregnancies, births and governmental costs. It outlines the prescribed approach used to identify, synthesise and evaluate the quality of the evidence and offers recommendations for future research. Assumptions, audience, definitions and conceptual framework The purpose of and methodology used in this critical literature review rests on three working assumptions. First, the primary audience consists *Corresponding authors Email: [email protected] [email protected] Department of Health Policy, Milken Institute School of Public Health at the George Washington University, Washington, DC, USA