The purpose of the study was to examine reproductive life planning practices among Title X family planning health care providers and clinical staff. Reproductive life planning is a program priority for Title X clinics, those that receive federal money for providing family planning services to low-income women and men. The goal of reproductive life planning is to decrease unwanted and unintended pregnancies and improve preconception health care however; this practice has not been described. First, a conceptual analysis was conducted to create a definition of reproductive life planning that was consistent with the literature. Reproductive life planning is a process that is centered on reproductive and other life goals and is personalized, collaborative, fluid, and focused on health-promotion. Second, a mixed methods design was used to examine reproductive life planning practices and qualitative interviews were conducted to explore barriers and facilitators to implementing reproductive life planning practices. Data were obtained from health care providers and clinical staff employed at Title X clinics in Illinois, Iowa, Minnesota, Missouri, Nebraska, and North Dakota. A total of 148 clinicians completed a web-based survey which was analyzed to describe which types of patients, the topics covered, and the frequency with which reproductive life planning was discussed during an office visit. Surveys were then examined to identify 20 providers to conduct qualitative interviews with to further explore reproductive life planning practices. The qualitative interviews were also performed to explore the barriers and facilitators clinicians face to practicing reproductive life planning. The results of the web-based questionnaire were examined mainly with medians and frequencies to examine reproductive life planning practices. Qualitative interviews were coded using a content analysis approach to two aims; one to examine how reproductive life planning was using during clinic visits and two, to identify the barriers and facilitators clinicians face when discussing reproductive life planning with patients. Findings from the survey and the interviews suggest that most clinicians are discussing pregnancy intentions with their patients. However, from the interviews, three types of scope of reproductive life planning emerged; those clinicians who screened their patients’ pregnancy intentions, those who planted the seed in the patient’s mind, and those who explored the context of a patient’s life and their goals to contextualize how pregnancy and childbearing would fit into their lives in order to clarify pregnancy intention and move toward the corresponding health behaviors. It is argued that the third group of providers is using reproductive life planning as intended by experts. Finally, barriers to RLP discussions were examined as well as approached providers used to overcome the barriers. In conclusion, many clinicians are practicing reproductive life planning as intended, however many are not. Improved training and protocols are needed to ensure clinicians are providing their patients with the best reproductive life planning discussions. Additionally, systemic structures, like access to quality family planning services, need to be improved to aid clinicians in helping their patient plan their families.

This dissertation examines the creation and development of the United States government's Title X family planning program from 1965 to 1988. It argues that Title X became controversial when its supporters shifted their focus from promoting family self-sufficiency to celebrating individual reproductive freedom. The new individualist arguments profoundly threatened many Americans who wanted government policy to support the patriarchal nuclear family. Support for federally-subsidized family planning programs in the 1960s rested on an ideology of nuclear family economic independence. Advocates reasoned that birth control services would enable poor Americans, especially African-Americans, to have children only within stable, self-sufficient marriages. Using these arguments, family planning advocates developed nearly-unanimous support for family planning programs among federal policymakers. In the early 1970s, though, family planning supporters embraced feminist and anti-racist critiques of their earlier ideas, leading them to promote subsidized family planning as a route to individual women’s reproductive freedom. In turn, the dissertation examines the growth of the New Right in reaction to the new liberal focus on individual freedom. While some dissenters had opposed family planning programs in the 1960s, this opposition mushroomed in the 1970s as opponents identified Title X as a threat to the family. Family planning opponents focused on two aspects of subsidized birth control programs that endangered the patriarchal nuclear family: abortion and teenagers’ access to contraception. Both of these issues jeopardized the husband’s and father’s authority over his dependents. In addition, opponents claimed that federal government spending on Title X overused their tax dollars, compromising their own ability to be self-sufficient and, thus, the survival of their own independent nuclear families. As a result, they mobilized in opposition to Title X in the 1970s and 1980s. The dissertation uses a wide variety of archival materials, government documents, and published sources to document the trajectory of debates over federally-funded family planning programs / History

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abstract: Nearly seven decades ago, the US government established grants to the states for family planning and acknowledged the importance of enabling all women to plan and space their pregnancies, regardless of personal income. Since then, publicly-funded family planning services have empowered millions of women, men, and adolescents to achieve their childbearing goals. Despite the recognized importance of subsidized family planning, services remain funded in a piecemeal fashion. Since the 1940s there have been numerous federal funding sources for family planning, including the Title V Maternal and Child Health Services Program, Office of Economic Opportunity grants, Title XX Social Services Program, Title X Family Planning Program, Medicaid, and the State Children’s Health Insurance Program, alongside state and local support. Spending guidelines allow states varying degrees of flexibility regarding allocation, to best serve the local population. With nearly two billion dollars spent annually on subsidized family planning, criticism often arises surrounding effective local program spending and state politics influencing grant allocation. Political tension regarding the amount of control states should have in managing federal funding is exacerbated in the context of family planning, which has become increasingly controversial among social conservatives in the twenty-first century. This thesis examines how Arizona’s political, geographic, cultural, and ethnic landscape shaped the state management of federal family planning funding since the early twentieth century. Using an extensive literature review, archival research, and oral history interviews, this thesis demonstrates the unique way Arizona state agencies and nonprofits collaborated to maximize the use of federal family planning grants, effectively reaching the most residents possible. That partnership allowed Arizona providers to reduce geographic barriers to family planning in a rural, frontier state. The social and political history surrounding the use of federal family planning funds in Arizona demonstrates the important role states have in efficient, effective, and equitable state implementation of national resources in successfully reaching local populations. The contextualization of government funding of family planning provides insight into recent attempts to defund abortion providers like Planned Parenthood, cut the Title X Family Planning Program, and restructure Medicaid in the twenty-first century. / Dissertation/Thesis / Masters Thesis Biology 2018

Government began legislating abortion in the mid nineteenth century and has controlled access to this service for women ever since. With the creation of hospital boards after WWII, state control over access became further entrenched. Regulations and restrictions since Roe v. Wade limit the availability of abortion services for women served by Medicaid and other social assistance programs. The existence of a class bias around access can be seen throughout the topic's history and legislation has unfairly targeted and therefore disproportionately affects poor women. The data show that these restrictions have no impact on the number of unintended pregnancies over the last 20 plus years. Without the ability to personally fund the procedure, poor women do not enjoy the same choices as women in other social classes. In the next decade, we are likely to experience more of the same without having a realistic conversation about Medicaid funding of abortion.

This study operationalized the five dimensions of health care access in the context of contraceptive service provision and used this framework to examine access to contraceptive care at health department (HD) (Title X funded) and federally qualified health center (FQHC) (primarily non-Title X funded) clinics in South Carolina and Alabama. A cross-sectional survey was conducted in 2017/18 that assessed clinic-level characteristics, policies, and practices related to contraceptive provision. Provision of different contraceptive methods was examined between clinic types. Survey items were mapped to the dimensions of access and internal consistency for each scale was tested with Cronbach's alpha. Scores of access were developed and differences by clinic type were evaluated with an independent t-test. The overall response rate was 68.3% and the sample included 235 clinics. HDs (96.9%) were significantly more likely to provide IUDs and/or Impants on-site than FQHCs (37.4%) (P < 0.0001). Scales with the highest consistency were Availability: Clinical Policy (24 items) (alpha = 0.892) and Acceptability (43 items) (alpha = 0.834). HDs had higher access scores than FQHCs for the Availability: Clinical Policy scale (0.58, 95% CL 0.55, 0.61) vs (0.29, 95% CL 0.25, 0.33) and Affordability: Administrative Policy scale (0.86, 95% CL 0.83, 0.90) vs (0.47, 95% CL 0.41, 0.53). FQHCs had higher access scores than HDs for Affordability: Insurance Policy (0.78, 95% CL 0.72, 0.84) vs (0.56, 95% CL 0.53, 0.59). These findings highlight strengths and gaps in contraceptive care access. Future studies must examine the impact of each dimension of access on clinic-level contraceptive utilization.