Appendices for Receipt of Selected Preventive Health Services for Women and Men of Reproductive Age — United States, 2011–2013

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Appendix A : Services Recommended in Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs

Service	Recommendation
Contraceptive services	Offer contraceptive services to all clients who wish to delay or prevent pregnancy.
Pregnancy testing and counseling	Offer pregnancy testing and counseling to all clients seeking this service.
Achieving pregnancy	Advise clients how to achieve pregnancy if they wish to become pregnant and are seeking this service.
Basic infertility services	Offer basic infertility services to infertile clients (i.e., those who have failed to achieve pregnancy after 12 mos or longer of regular unprotected intercourse) seeking this service. Earlier assessment may be justified for clients with identified risk factors.
Preconception health services
Folic acid*,†	All women planning or capable of pregnancy should be counseled about the need to take a daily supplement containing folic acid.
IPV*,†	Screen all women of childbearing age for IPV and provide/refer to intervention services, as indicated.
Alcohol and other drug use†	Screen clients for use of alcohol and other drugs and provide/refer for behavior counseling, as indicated.
Tobacco use†	Screen clients for tobacco use and provide/refer for tobacco cessation interventions, as indicated; provide adolescents with interventions to prevent initiation of tobacco use.
Immunizations	Screen for immunization status and provide/refer for immunization, as indicated by ACIP: influenza (annually); tetanus (once every 10 yrs); and HPV and hepatitis B (one-time receipt of vaccine series).
Depression	Screen all clients for depression when staff-assisted depression care supports are in place to ensure accurate diagnosis, effective treatment, and follow-up. USPSTF notes that the optimum interval for screening for depression is unknown; however, they suggest that a pragmatic approach might be to screen all adults who have not been screened previously and to use clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine whether additional screening of high-risk patients is warranted.
BMI†	Assess client’s height, weight, and BMI and provide/refer adults with obesity for intensive counseling and behavioral interventions.
Blood pressure	At the time QFP was published, the USPSTF recommendation was to screen persons with blood pressure <120/80 mm Hg routinely. For adults who are prehypertensive (i.e., 120–130 mm Hg/80–89 mm Hg), the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends annual screening. AAP recommends annual screening for adolescents. In 2015, USPSTF updated its recommendation on blood pressure screening to indicate that adults at increased risk (i.e., black, with high normal blood pressure, with obesity or overweight, or aged >40 yrs) should be screened every year, while persons at low risk (aged 18–39 yrs with no risk factors) should be screened every 3–5 yrs.
Diabetes	At the time QFP was published, the USPSTF recommendation was to screen for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) >135/80 mm Hg. In 2015, USPSTF changed its recommendations to indicate adults aged 40–70 yrs with obesity or overweight should be screened for type 2 diabetes. USPSTF notes that evidence on the optimal rescreening interval for adults with an initial normal glucose test result is limited; however, rescreening every 3 yrs might be a reasonable approach for adults with normal blood glucose levels.
STD services
Chlamydia	At the time QFP was published, the CDC recommendation was to screen annually for chlamydia infection all sexually active young females aged ≤25 yrs and among sexually active women aged >25 yrs with risk factors. Screening of male clients can be considered at sites with high prevalence of chlamydia infection and MSM. Recommendations are to provide/refer for treatment, as indicated. In 2015, CDC STD guidelines changed the age for screening all sexually active young women from ≤25 yrs to <25 yrs. Recommendations for women above this age with additional risk factors and male clients remain the same.
Gonorrhea	Screen all women at risk for gonorrhea infection annually, including women aged <25 yrs. Screen MSM clients. Provide/refer for treatment, as indicated.
Syphilis	Screen persons at risk for syphilis infection, including MSM, commercial sex workers, persons who exchange sex for drugs, persons in adult correctional facilities, and persons living in communities with high prevalence of syphilis.
HIV/AIDS	Screen all clients aged 13–64 yrs for HIV/AIDS on a routine basis and rescreen all persons at high risk for HIV infection annually. Refer for care, as indicated.
Hepatitis C	Provide one-time testing for hepatitis C infection for persons born during 1945–1965 and routine screening for persons at high risk for hepatitis C infection. Persons with HIV infection should be tested at least annually for hepatitis C infection. Provide/refer for treatment, as indicated.
Related preventive health
Cervical cytology*	Screen women aged 21–65 yrs with cervical cytology (Pap smear) every 3 yrs or women aged 30–65 yrs with a combination of cytology and HPV testing every 5 yrs. Refer for further diagnosis and treatment, as indicated.
Breast cancer screening*	Screen women aged 50–74 yrs biennially with mammogram; women aged <50 yrs can be considered if other conditions support providing the service. Refer for further diagnosis and treatment, as indicated.

Abbreviations: AAP = American Academy of Pediatrics; ACIP = Advisory Committee on Immunization Practices; BMI = body mass index; HIV/AIDS = human immunodeficiency virus/acquired immunodeficiency syndrome; HPV = human papillomavirus; IPV = intimate partner violence; mm Hg = millimeters of mercury; MSM = men who have sex with men; Pap = Papanicolaou; QFP = Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs; USPSTF = U.S. Preventive Services Task Force; STD = sexually transmitted disease.
* This service is only recommended for female clients.
^† USPSTF has not recommended a screening interval because evidence is lacking to determine the optimal interval.

 

Appendix B : Adverse Health Outcomes Targeted for Prevention Through Services Recommended in Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs, by Age

Outcome	Total (15–44 yrs)		15–19 yrs	20–24 yrs	25–29 yrs	30–34 yrs	35–39 yrs	40–44 yrs
Unintended pregnancies, 2011*,†
No. of unintended pregnancies (in 1,000s)	2,779§		430	878	691	444	328¶
Unintended pregnancy (rate per 1,000 population)**	45§		41	81	66	43	16¶
Pregnancies unintended (%)	45§		75	59	42	31	34¶
Teen births, 2015††
No. of teen births (in 1,000s)	N/A		230	N/A	N/A	N/A	N/A	N/A
Teen births (rate per 1,000 population)§§	N/A		22.3	N/A	N/A	N/A	N/A	N/A
Teen births that are repeat births (%)¶¶	N/A		16.7	N/A	N/A	N/A	N/A	N/A
Birth spacing, 2014***
Singleton births conceived <18 mos after previous live birth (%)	28.9†††		22.4§§§	27.1	29.3	34.9	44.1¶
Infant health, 2015††
Births that are preterm (%)¶¶¶	9.6†††		9.9§§§	9.3	8.9	9.4	11.1	13.7
Births with low birth weight (%)****	8.1†††		9.5§§§	8.4	7.5	7.5	8.7	10.8
Infertility, 2011–2013††††, §§§§
Married and cohabiting women (% [95% CI])	6.3 (4.9–7.7)		—¶¶¶¶	4.9 (1.3–8.5)	5.5 (2.6–8.5)	4.2 (2.4–6.0)	8.5 (4.6–12.3)	8.3 (5.5–11.1)
Obesity, 2011–2012*****
Overweight women (% [95% CI])†††††	25.2 (21.4–29.1)		14.9 (9.7–20.0)	21.7 (14.2–29.3)	29.5 (25.0–33.9)§§§§§		28.3 (22.4–34.2)¶¶¶¶¶
Obese women (% [95% CI])†††††	30.2 (27.1–33.4)		16.4 (10.0–22.9)	26.9 (18.3–35.5)	34.4 (29.4–39.4)§§§§§		34.9 (29.9–39.9)¶¶¶¶¶
Hypertension, 2011–2012*****
Women with high blood pressure or medication for high blood pressure (% [95% CI])******	8.8 (6.8–10.7)		—	—	6.4 (4.3–8.5)§§§§§		19.6 (15.0–24.2)¶¶¶¶¶
Diabetes, 2011–1012*****
Women ever told by health care professional they had diabetes (% [95% CI]s	2.5 (1.7–3.4)		—	—	1.2 (0.6–1.8)§§§§§		5.9 (3.7–8.2)¶¶¶¶¶
Diagnoses of HIV infection, 2014 estimated,†††††† both sexes
No. of diagnoses of HIV infection	32,931		1,854	7,983	7,963	6,093	4,750	4,288
Rate of diagnoses of HIV infection (per 100,000 population)	13.9§§§§§§		8.7	34.4	35.8	28.0	23.5	20.6
Diagnoses of HIV infection, 2014 estimated,†††††† males
No. of diagnoses of HIV infection	27,371¶¶¶¶¶¶		1,505	7,083	6,853	4,970	3,659	3,301
Diagnoses of HIV infection, 2014 estimated,†††††† females
No. of diagnoses of HIV infection	5,561		349	901	1,110	1,123	1,091	987
Diagnoses of AIDS, 2014 estimated,******* noncumulative, both sexes
No. of diagnoses of AIDS	12,255		233	1,485	2,555	2,641	2,615	2,726
Rate of diagnoses of AIDS (per 100,000 population)	6.6§§§§§§		1.1	6.4	11.5	12.1	13.0	13.1
Diagnoses of AIDS, 2014 estimated,¶¶¶¶¶¶ noncumulative, males
No. of diagnoses of AIDS	9,334		166	1,236	2,090	2,013	1,878	1,951
Diagnoses of AIDS, 2014 estimated,¶¶¶¶¶¶ noncumulative, females
No. of diagnoses of AIDS	2,922		68	249	465	628	737	775
STDs, 2014, number and rate, women*******
No. of chlamydia cases reported	981,230		303,294	405,876	161,793	67,060	29,545	13,662
Chlamydia cases reported per 100,000 women	627.2†††		2,941.0	3,651.1	1,523.4	633.7	300.9	130.3
No. of gonorrhea cases reported	156,589		44,399	59,329	28,899	13,988	6,654	3,320
Gonorrhea cases reported per 100,000 women	101.3†††		430.5	533.7	272.1	132.2	67.8	31.7
No. of syphilis cases reported	1,654		262	503	361	248	177	103
Syphilis cases reported per 100,000 women	1.1†††		2.5	4.5	3.4	2.3	1.8	1.0
STDs, 2014, number and rate, men*******
No. of chlamydia cases reported		412,036	77,908	159,804	91,729	45,990	22,894	13,711
Chlamydia cases reported per 100,000 men		278.4†††††††	718.3	1,368.3	837.0	430.6	234.0	132.3
No. of gonorrhea cases reported		169,124	23,981	56,714	40,602	24,349	14,129	9,349
Gonorrhea cases reported per 100,000 men		120.1†††††††	221.1	485.6	370.5	228.0	144.4	90.2
No. of syphilis cases reported		14,277	761	3,632	3,727	2,635	1,868	1,654
Syphilis cases reported per 100,000 men		11.7†††††††	7.0	31.1	34.0	24.7	19.1	16.0

Abbreviations: AIDS = acquired immunodeficiency syndrome; HIV = human immunodeficiency virus; CI = confidence interval; N/A = not applicable; STDs = sexually transmitted diseases.
* Source: Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008–2011. N Engl J Med 2016;374:843–52.
^† Pregnancies were classified as unintended if they were either mistimed or unwanted; pregnancies were classified as intended if they were desired at the time they occurred or sooner.
^§ Includes women aged ≥15 years. Adolescents aged <15 years were excluded because of insufficient data.
^¶ Includes women aged ≥35 years.
** Number of unintended pregnancies per 1,000 women aged 15–44 years or specific age group. For women aged ≥35 years, the numerator is the number of unintended pregnancies among women aged ≥35 years and the denominator is the number of women aged 35–44 years.
^†† Source: Martin JA, Hamilton BE, Osterman MJK, Driscoll AK, Mathews TJ. Births: final data for 2015. Natl Vital Stat Rep 2017;66:1–69.
^§§ Births per 1,000 female teens aged 15–19 years.
^¶¶ The percentage of births among teenagers aged 15–19 years that were second or higher order, among all births where birth order was not missing.
*** Source: Thoma ME, Copen CE, Kirmeyer SE. Short interpregnancy intervals in 2014: differences by maternal demographic characteristics. NCHS Data Brief 2016;240:1–8.
^††† Includes women of all ages.
^§§§ Includes all women aged ≤19 years.
^¶¶¶ Less than 37 completed weeks of gestation on the basis of the obstetric estimate.
**** Birth weight <2,500 grams.
^†††† Source: National Survey of Family Growth, 2011–2013; special data tabulation.
^§§§§ Percentage of all married and cohabiting women aged 15–44 years who are infertile (i.e., who are not surgically sterile and have had at least 12 consecutive months of unprotected sexual intercourse without becoming pregnant).
^¶¶¶¶ Does not meet reliability standards.
***** Source: National Health and Nutrition Examination Survey, 2011–2012; special data tabulation.
^{†††††} For women aged 15–19 years, overweight was defined as ≥85th and <95th percentile of body mass index (BMI) for age; obesity was defined as ≥95th percentile. For women aged 20–44 years, overweight was defined as BMI ≥25 and <30; obesity was defined as BMI ≥30.
^§§§§§ Includes women aged 25–34 years.
^¶¶¶¶¶ Includes women aged 35–44 years.
****** For women aged 15–19 years, hypertension was defined as ≥95th percentile systolic or diastolic blood pressure given age and height percentile or use of medication to control blood pressure. For women aged 20–44 years, hypertension was defined as ≥140 mm Hg systolic blood pressure, ≥90 mm Hg diastolic blood pressure, or use of medication to control blood pressure.
^{††††††} Source: National HIV Surveillance System. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. The estimated numbers and rates of diagnoses of HIV infection were made on the basis of data from 50 states and six dependent areas. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing risk-factor information, but not for incomplete reporting. CDC. HIV surveillance report, 2014; vol. 26. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2014-vol-26.pdf (Tables 1b and 5b).
^§§§§§§ Includes women and men of all ages.
^¶¶¶¶¶¶ Source: National HIV Surveillance System. The estimated numbers and rates of stage 3 infection (AIDS) were made on the basis of data from 50 states and six dependent areas. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing risk-factor information, but not for incomplete reporting. CDC. HIV Surveillance Report, 2014; vol. 26. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2014-vol-26.pdf (Tables 2b and 6b).
******* Source: Nationally Notifiable Disease Surveillance System. 2014 sexually transmitted disease surveillance report. Chlamydia: https://www.cdc.gov/std/stats14/tables/10.htm; gonorrhea: https://www.cdc.gov/std/stats14/tables/21.htm; and syphilis: https://www.cdc.gov/std/stats14/tables/35.htm.
^{†††††††} Includes men of all ages.

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