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Quality measures exist for many areas of medicine including 700 National Quality Forum endorsed measures. However there is not yet a measure for contraception. A number of others have highlighted the need for one or more quality measures for contraception. For example the recommendations from the Association for Reproductive Health Professionals Sexual and Reproductive Health (SRH) Workforce Summit include "Develop one Healthcare Effectiveness Data and Information Set (HEDIS) measure on SRH" and "Define SRH quality metrics for use in new models of care." A quality measure that affected how much health centers get paid by insurers would encourage providers to focus on contraception and would provide valuable information to managers on how health centers and agencies are performing. Primary care providers in particular have many demands on their time. They understandably allocate their time in part based on financial incentives. Establishing a quality measure for contraception that affects payment is a key tool in the effort to have primary care sites provide higher quality contraceptive services.
Measuring Social Impact
A quality measure is also important for management decisions about how to maximize social impact. These decisions face health care organizations and donors both in government and at private foundations. The Hewlett Foundation has a particular interest in measuring impact as we describe our grantmaking approach as "outcome-focused grantmaking." We attempt to specifically articulate the outcome we are trying to achieve and to measure whether our investments are making progress towards that outcome. Health centers exist in large part to achieve social impacts such as improving health. Health centers also need to consider the financial bottom line. However, it is essential that managers consider the impact of financial decisions on the achievement of social impact. If we want to make good management decisions, we need clear measures of social impact. A quality measure for contraception could enable health center managers to track the impact of financial and other operational decisions on the health center's social impact. However, few health centers use social impact measures because they are difficult to calculate. The problem is that the ultimate outcomes we are trying to change such as unintended pregnancy are difficult to measure.
The Contraceptive Protection Index
The Contraceptive Protection Index offers a promising solution. Although it does not measure the incidence of the condition we are trying to prevent (unintended pregnancy) it does measure the delivery of the preventative treatment, effective contraception. Measuring whether the effective treatment is being provided to those in need is one way to measure quality. The contraceptive protection index is a weighted average. It is calculated by multiplying the typical use efficacy rates for each contraceptive method (how well does the method protect against pregnancy in the real world) by the percent of women using each method. The contraceptive protection index is an improvement over simply measuring the percent of women that use IUDs and implants because the contraceptive protection index also takes into account the efficacy of the methods used by those women not using IUDs and implants. Pill and condom users are generally the majority of users at most health centers so a measure of IUD and implant use alone obscures what impact most health centers are having on the majority of their clients.
Using the most recent data on typical use efficacy rates and the published contraceptive method mix for participants in the Contraceptive CHOICE Project in St. Louis, one can calculate that project's contraceptive protection index of 97.8%. This calculation is based on the methods used by those women who received contraception because in the CHOICE project all women received a method of contraception. An improvement would be to calculate the index for all women served by a given health center who are not planning to get pregnant in the next year. This would likely include some women who left the health center with no method despite their desire to avoid pregnancy. It is essential that these women are captured in the index so that it reflects all women who are not planning to get pregnant served by a particular health center or in a given population. A 2006 report from the Guttmacher Institute includes such a calculation. Estimating the Impact of Expanding Medicaid Eligibility for Family Planning Services by Frost, Sonfield and Gold and funded by the Hewlett Foundation notes in table A9 the possible increase in the contraceptive protection index among women that would become eligible for no cost contraception if Medicaid were expanded.
Quality not Quantity
While serving more women has some benefits, it may not always mean more impact. Imagine one health center which provides oral contraceptives to 1,000 women in a month, and another health center which sees only 900 but provides them with IUDs. More women served may seem like more impact. But if part of the goal of the health center is to help women avoid unintended pregnancy then the health center that saw fewer women but provided them with a far more effective contraceptive method is the one that achieved more impact.
If one of our goals is to reduce unintended pregnancy, we must measure not only the quantity of clients served but also the quality and effectiveness of the services delivered. If we want health centers whose primary focus is not family planning to provide quality family planning services, we need a quality measure for contraception that is tied to payment. The contraceptive protection index would be an excellent place to start.
Peter Belden is a Program Officer for the Global Development and Population Program at The William and Flora Hewlett Foundation.