Reenvisioning Title X to Meet Early Pregnancy Needs

TITLE X PROGRAM

Established in 1970 and administered by the US Department of Health and Human Services Office of Population Affairs (OPA), Title X is the nation’s only dedicated domestic federal family planning program. Title X services include contraceptive counseling and management, fertility services, screening and treatment of sexually transmitted infections, and reproductive preventive health interventions such as the human papillomavirus vaccination.⁷ In its most recent Title X five-year program plan, OPA has prioritized health equity, expanded service access, and emphasized high-quality service delivery.⁸ The program explicitly does not fund abortions, but supports nondirective pregnancy options counseling and referrals to prenatal or abortion care.⁷

“Pregnancy testing and counseling” is explicitly included within the scope of Title X.⁷ Although point-of-care urine pregnancy testing is offered in Title X programs, this is insufficient to confirm the pregnancy location, gestational age, or presence of multiple gestations. Definitive pregnancy confirmation with ultrasound is within the mandate of Title X. Yet, to our knowledge, most Title X clinics do not routinely offer bedside sonographic pregnancy confirmation. This may reflect lack of funding for ultrasound equipment, a paucity of providers with the skills needed to perform ultrasounds, or merely a general perception that these services would not fall under the scope of Title X. Approximately 12% of Title X grantees are Planned Parenthoods, most of which do provide early pregnancy confirmation with pregnancy testing and ultrasound, although this does not often fall under Title X service provision.^9,10 We propose increased support for Title X clinics to provide basic pregnancy confirmation services (urine pregnancy testing and bedside ultrasound) for patients with uncomplicated early pregnancies.

AN OPPORTUNITY FOR EQUITABLE PREGNANCY CARE

The United States has seen an astonishing rise in maternal mortality. Black and Indigenous pregnant individuals are two to three times more likely than their White counterparts to have a pregnancy-related death, reflecting deep-seated structural racism in the United States and in health care.¹¹ Additionally, pregnant individuals with lower incomes, those from rural communities, and adolescents suffer from diminished access to reproductive health services.^12–14 Thus, any efforts to improve health care in pregnancy must be guided by a lens of equity.

Health equity and access are cornerstones of the Title X program. In 2022, Title X funds supported a network of 4126 service sites in all 50 states and the District of Columbia, serving 2.6 million clients over 4.1 million encounters.¹⁵ Of these clients, only 65% were insured, and of the insured clients, 66% had public insurance. Furthermore, 31% of Title X users identified as Black, Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, or more than one race, and 37% identified as Hispanic or Latinx. Nineteen percent had limited English proficiency.¹⁵ Given the diversity of patients served by Title X sites, integrating early pregnancy diagnostic services into Title X programs may facilitate access to preventive, obstetric, and abortion care for minoritized communities, and result in more equitable pregnancy outcomes.

TITLE X: AN ALTERNATIVE TO CRISIS PREGNANCY CENTERS

CPCs provide free or low-cost pregnancy testing and “non-diagnostic” ultrasound, and disseminate disinformation to dissuade clients from seeking abortions.¹⁶ Pregnancy confirmation services at CPCs are widely accessible¹⁰ and commonly utilized,¹⁷ and early pregnancy confirmation is a leading reason clients seek care at CPCs.¹⁸ Despite broad availability, ultrasounds at CPCs are often conducted in the absence of any medical professionals; one large study of CPCs found that only 16% had a physician on staff, and only 25% had a registered nurse.¹⁶

In Pennsylvania, decades of state-funded support of CPCs ended in 2023.¹⁹ In January 2024, funds were reallocated to existing reproductive care sites, the majority of which are Title X grantees. Such policy changes, which combat deceptive practices by CPCs and redirect funding toward essential health care, are commendable. However, it is crucial to ensure that the recipients of this redirected funding can provide the very service that often leads people to seek care at CPCs: sonographic pregnancy confirmation. Provision of early pregnancy ultrasound and evidence-based early pregnancy counseling can both meet patient needs and reduce the harms of patients seeking care in nonmedical settings such as CPCs. The continued existence of CPCs throughout the country is reflective of a void in our medical system, namely, a dearth of evidence-based, patient-centered comprehensive pregnancy confirmation. Defunding CPCs is a first step in improving care. The next step is to support equitable access to comprehensive pregnancy confirmation.

EARLY PREGNANCY ENGAGEMENT TO IMPROVE QUALITY

Regardless of whether a person plans to continue or terminate a pregnancy, earlier access to pregnancy confirmation is beneficial. For those who continue a pregnancy, sonographic pregnancy confirmation promotes more accurate pregnancy dating and early entry to prenatal care—a long-standing strategy for improved birth outcomes. This early engagement is an opportunity for earlier initiation of proven preventive interventions such as folic acid supplementation and aspirin for preeclampsia prevention, and for medication review for teratogenic drugs or expedited referrals to maternal–fetal medicine or social services as indicated. These preventive interventions improve the quality of pregnancy care and should be broadly incorporated into the Title X setting. Furthermore, for the 36% of Title X patients who are uninsured,⁹ a new pregnancy diagnosis may provide qualification for Medicaid enrollment, and pregnancy confirmation in the Title X setting may help to expedite engagement with these resources.

For individuals desiring pregnancy termination, early engagement with abortion care is associated with fewer abortion complications and improved access to both medication and procedural abortion options. As patients navigate the patchwork of onerous regulations, gestational age limits, and abortion bans in the post-Dobbs era, early pregnancy diagnosis is critical to ensure timely health care access. Although sonographic pregnancy confirmation is not needed for safe abortion care in most cases, some individuals may desire pregnancy confirmation before proceeding with abortion care.

EXPANDING THE EARLY PREGNANCY ASSESSMENT CLINIC

Early pregnancy assessment clinics (EPACs) are an integrated model for outpatient management of the 25% of patients who experience early pregnancy complications such as vaginal bleeding or pain.⁴ This model is well-established in Canada and the United Kingdom, and has been growing in the United States.²⁰ Most EPACs confirm pregnancy location and viability in patients with first-trimester vaginal bleeding or pelvic pain, with comparable safety and improved cost and efficiency compared with the ED setting.^21,22 EPACs ideally integrate miscarriage, ectopic management, and abortion care into a single setting. Although EPACs provide an important service to individuals with early pregnancy complications (and, in some models, to patients seeking abortion care), they often do not have the capacity to provide more routine early pregnancy care to the 75% of individuals without early pregnancy pain or bleeding, nor are they designed to do so.

The Title X program, given its vast reach across the nation, could exist as a complement to EPACs in early pregnancy. The focus of Title X early pregnancy services would be on confirmation of intrauterine pregnancy for individuals without bleeding or pain, including sonographic confirmation of pregnancy dating. Although some Title X clinics may also have the capacity to manage individuals experiencing early pregnancy complications, many would still likely refer patients with symptomatic pregnancies of unknown location, miscarriages, or ectopic pregnancies to an EPAC, ED, or outpatient general gynecological office setting as deemed appropriate. These workflows should be determined by individual clinical sites, depending on staffing and resource availability. In either scenario, patient needs are met by facilities licensed and capable of providing the evidence-based care that patients are often currently seeking outside the formal health care system.

CONSIDERATIONS AND FUTURE DIRECTIONS

In the era of broad access to high-sensitivity home pregnancy testing, for Title X clinics to operate within their scope of “pregnancy testing and counseling,” capacity building for sonographic pregnancy confirmation in alignment with ACOG first-trimester recommendations is needed. For the small proportion of Title X clinical sites that are already equipped with ultrasound and trained personnel to initiate early pregnancy confirmation services, we encourage inclusion of these services within Title X programming. For most Title X clinics, OPA investment in early pregnancy service expansion through provision of ultrasound equipment and point-of-care ultrasound training of personnel may be necessary. Since 2014, there have been no increases in Title X funding and no adjustments for inflation.⁹ To appropriately support the family planning needs of Title X clients, substantial funding increases are needed. We call for increased federal funding for Title X, to better equip OPA to support training Title X clinicians in early pregnancy imaging and management, to develop clinical protocols and guidelines for referral in early pregnancy, and to ensure access to appropriate equipment, including bedside ultrasound machines. This will require federal investment and institutional partnerships. Such an investment will reap long-term benefits, allowing for improved access to comprehensive early pregnancy confirmation care nationwide. Furthermore, continued advocacy around insurance reimbursement for point-of-care early pregnancy ultrasound is necessary for the sustained provision of these services within the Title X clinical setting.

Although the Title X program remains steadfast in its mission-driven provision of family planning services nationally, particularly to minoritized communities, it has historically been subject to notable disruptions and obstacles related to changes in administration. In 2019, for example, the Trump administration issued regulations prohibiting Title X programs from providing abortion referrals or from locating in spaces where abortion care was provided, resulting in many clinics withdrawing from Title X funding and a 21% reduction of Title X client volume. Some Title X funds were even redirected to CPCs during this time, further distancing patients from much-needed evidence-based pregnancy care. Although these obstructive regulations were reversed by the Biden administration in 2021, such fluctuations point to a vulnerability in the current Title X structuring. As we embark on a presidential election year, it is essential to strengthen and protect the essential reproductive health care provided by Title X sites. As a first step, to prevent CPCs from receiving Title X funds in the future, we call on the OPA to permanently mandate nondirective pregnancy options counseling as a requirement for all Title X funding recipients.

Particularly in the wake of the assault to reproductive rights brought on by Dobbs v Jackson Women’s Health Organization, access to swift, safe, confidential, and evidence-based early pregnancy care is more important now than ever. The provision of pregnancy confirmation services in Title X clinics should never prevent nor delay a patient from seeking an abortion (in fact, ultrasound confirmation of pregnancy is often not needed for safe abortion care) but should be available for patients, including those who desire pregnancy confirmation prior to seeking an abortion. Moreover, Title X clinics provide abortion referrals and may provide patients with accurate information about accessing safe abortion care. It should also be noted that, although the mean age of pregnancy awareness in the United States is 5.5 weeks, many people—particularly younger people—do not learn of their pregnancies until later, with one in three pregnant people not knowing their pregnancy status until six weeks or later.¹ Thus, although early pregnancy services should be made available to all pregnant individuals, it is critical to acknowledge the significant number of people who do not have access to early pregnancy diagnoses, and will suffer disproportionate harm from early abortion bans.

Pregnancy confirmation services, including sonographic pregnancy confirmation, fall within the scope of Title X services, but have not historically been integrated into Title X clinical programs. In pursuance of the OPA priorities of equity, access, and quality, we call for the addition of comprehensive pregnancy confirmation services at Title X clinical sites as a means of improving and advancing the state of reproductive health care nationwide.