The Evidence, Potential Consequences, and Rationale for Core Recommendations

The Expert Workgroup (EWG) considered 21 core recommendations for this update. As outlined in Exhibit 21, three of the 21 recommendations are new. Seven are updates to the original QFP, and three were retained from the original QFP. Six were reframed or integrated into other recommendations and two were removed. 

The 10 core recommendations for the 2024 QFP are:

1. Guiding Principles for Sexual and Reproductive Health (SRH) Care and Approaches to Care (new)
2. Screening for the Need and Desire for SRH Services (new)
3. STI and HIV Services (updated)
4. Family Building (new)
5. Pregnancy Options Counseling (updated)
6. Person-Centered Contraceptive Service Delivery (updated)
7. Screening and Other Preventive Health Care Services (updated)
8. Using Performance Measures to Track and Improve Quality of Care (updated)
9. Contraceptive Services – Availability of a Broad Range of Methods (retained)
10. Youth-Friendly Services (retained)

Each of these 10 core recommendations is accompanied here by a summary of relevant evidence, a list of potential consequences of implementing the recommendation, and the rationale for the recommendation. In the review, responses to the recommendations were received from 22 members.

Exhibit 21. Overview of Updates to the QFP Recommendations

The 10 Core Recommendations

1. Guiding Principles for Sexual and Reproductive Health (SRH) Care and Approaches to Care (new)

Recommendation: Quality SRH care is person centered, evidence based, inclusive, accessible, trauma informed, and acknowledges and works to mitigate all forms of bias, including racism, ableism, ageism, and bias based on disability status, weight, sexual orientation, and/or gender identity. Providers and health care settings can rely on overarching approaches to offer quality care—including shared decision making, where the health care provider and patient work jointly to make decisions about care; quality counseling techniques, such as establishing rapport, personalizing discussions, and providing accurate and understandable information; ensuring informed consent to enable individuals to make decisions about their own care; and guaranteeing privacy and confidentiality for all people seeking SRH care, to ensure safety and trust.

Quality of evidence: A systematic review was not conducted. These principles and approaches were derived from reviews of other relevant guidelines developed by the federal government and medical associations (for example, CDC, SAMHSA, and ACOG), evidence on patient experiences with SRH care, and expert opinion.

Potential consequences: More providers will offer, and more people will receive, quality SRH care, improving patients’ experiences and outcomes. Many things can impact service sites' ability to offer quality care, including systemic racism and other forms of bias; provider scope; facility capacity; referral networks; and the legal, financial/insurer, and regulatory environment.

Rationale: This content introduces fundamental principles and approaches to guide quality SRH care delivery for all people, regardless of professional role and setting. It provides actionable suggestions for integrating the equity principles described in the document into program design and clinical care and offers guidance about overarching approaches to care. Services that are offered based on these principles and approaches are core to the federal government’s efforts to promote equitable access to quality reproductive health care. Twenty-two EWG members agreed to this recommendation in 2024.

Learn More: Section 3. Fundamentals of Sexual and Reproductive Health Care Delivery

2. Screening for the Need and Desire for SRH Services (new) 

Recommendation: Asking about a person’s needs and experiences, taking an open-ended sexual history, and screening for specific services can help providers (1) ensure people get services that are medically appropriate and in line with their personal needs and preferences, (2) inform people about available services, and (3) educate people about how they can care for themselves. Providers and health care settings may select a tool or suite of tools to use based on where various tools have been tested, the population(s) being served, and health record considerations. It is generally recommended to screen patients at an initial encounter and then on a regular basis as determined by a schedule that providers or their organizations create based on patient needs, performance indicators, and other factors. While evidence was insufficient to recommend any specific screening tool or approach, several tools were identified and mentioned in the report, e.g., Parenthood/Pregnancy Attitude, Timing, and How important is pregnancy prevention (PATH), and Self-Identified Need for Contraception (SINC).  Of note, the reproductive life plan (RLP) approach is no longer endorsed given a rich body of literature suggesting that many people do not relate to the idea of RLP and that a pregnancy planning framework may be discordant with many people’s lived realities. 

Quality of evidence: A systematic review was conducted that focused on screening to assess patients’ needs and desires for SRH services;25 the recommendation was made on the basis of findings from this systematic literature review and expert opinion. Of the 65 articles that met the inclusion criteria for this review, 28 assessed the barriers and facilitators providers experience when screening to identify people’s needs and desires for SRH services, patients’ experiences with different tools and approaches to identify SRH needs and desires, or whether there is a relationship between the use of different screening tools and approaches to identify SRH service needs and desires and the receipt of these services. There was not enough evidence to recommend any specific screening tool or approach. However, providers reported that screening tools for STI and pregnancy-related services were most likely to be adopted when they were quick to administer and could be integrated into existing workflows. Patients expressed a preference for screening tools that promoted shared decision making and bodily autonomy. The recommendation is also supported by reviews of other U.S. public health and medical guidelines (for example, ACOG, ASRM) and expert opinion.   

Potential consequences: More providers will ask patients about their needs and expectations and use evidence-based screening tools. More people will receive services that are medically appropriate and in line with their personal needs and preferences, understand what services are available and what might be recommended for them, and understand how they can care for themselves. There is a risk of over-screening if recommendations are not followed. 

Rationale: A variety of approaches have been tested for screening patients for those SRH services that relate to preventing or preparing for pregnancy—for example, contraceptive care, family building, and preventive health services. There is not enough evidence to recommend a particular tool or approach; therefore, the tools suggested in the report were identified by an environmental scan commissioned by OPA for the QFP update and endorsed by the EWG. Twenty-two EWG members agreed to this recommendation in 2024.

Learn More: Section 4. Determining an Individual’s Need and Desire for Services 

3. STI and HIV Services (updated)

Recommendation: CDC’s STI and HIV screening, testing, and treatment guidelines are the foundation of STI and HIV care, including STI and HIV risk assessment; prevention strategies including prevention counseling, pre-exposure vaccination, and prophylactic measures (pre and post exposure); screening for STI and HIV; and treatment for individuals and their partners.

Quality of evidence: A systematic review was not conducted. The recommendation was made on the basis of CDC guidelines, USPSTF recommendations, and expert opinion.

Potential consequences: More individuals will receive person-centered and evidence-based STI and HIV health services, which could improve individual and population health. Provider scope, facility capacity, referral networks, and the legal, financial/insurer and regulatory environment will affect the ability of service sites to offer the full range of STI and HIV services.

Rationale: STI and HIV prevention, screening, testing, and treatment services are essential to helping people achieve optimal sexual and reproductive health. By providing equitable, accessible, and high quality STI services and integrating them into SRH and other prevention services, providers can help address stigma related to STI and HIV testing and treatment and improve the health of individuals. Twenty-two EWG members agreed to this recommendation in 2024.

Learn More: Section 4. Determining an Individual’s Need and Desire for Services, Section 6. STI and HIV Services, and Section 10. Screening and Other Preventive Health Care Services

4. Family Building (new)

Recommendation: The provider’s role is to offer personalized, non-biased, nonjudgmental, medically appropriate care to meet the needs and desires of individual patients related to family building. For persons who wish to carry a pregnancy and give birth, providers can help enable healthy pregnancy by providing pre-pregnancy care and offering basic fertility services as well as providing referrals to prenatal care for those who are planning to continue a pregnancy. Depending on the scope of practice and clinical setting, providers may offer or refer patients for medically assisted reproduction services—including comprehensive infertility evaluations, medications to increase fertility, therapeutic donor insemination, and intrauterine insemination. Providers can also offer resources for adoption services for patients who want to explore building their family through adoption.

Quality of evidence: A systematic review was not conducted. The recommendation was made on the basis of reviews of other relevant recommendations developed by the federal government and medical associations (for example, CDC, ACOG, and ASRM), and expert opinion.

Potential consequences: More individuals will receive health services related to family building. Provider scope and knowledge, systemic bias, facility capacity, referral networks, payor policies and benefits, and the legal and regulatory environment will affect the ability of service sites to offer comprehensive family building services.

Rationale: Family building can present social, economic and systems-levels challenges. The services that enable many LGBTQI+ people, unpartnered people, and people experiencing infertility to achieve their reproductive goals and build families are often expensive, not covered by insurance, and inaccessible, especially to people from marginalized groups. In addition, people from these groups may face stigma or discrimination in the process of family building. Twenty-one EWG members agreed to this recommendation in 2024. One member disagreed because the recommendation did not discuss the cost, financial impact or lack of insurance coverage for fertility services. 

Learn more: Section 7. Family Building

5. Pregnancy Options Counseling (updated)

Recommendation: People with a positive pregnancy test should be offered information and non-directive counseling on pregnancy options: parenting, adoption, or abortion. The goal of pregnancy options counseling is to equip people with the information and resources needed to support a course of action. This includes offering factual, neutral, nonjudgmental information about each option; screening for social needs; and giving contact information for other health care providers and community resources if indicated, requested, and permitted. 

Quality of evidence:  A systematic review was not conducted. The recommendation was made on the basis of reviews of other U.S. public health and medical guidelines (for example, ACOG, Society of Family Planning, AAP) and expert opinion.

Potential consequences: More providers will offer options counseling and conduct screening for social needs. More patients will receive, request, or refuse referrals and resources or information lists about all pregnancy options. Provider scope, facility capacity, referral networks, and the legal, financial/insurer, and regulatory environments will affect service sites’ ability to offer pregnancy options counseling.

Rationale: Clinical interactions surrounding pregnancy confirmation provide critical opportunities to discuss options, coordinate care, and mitigate risk. U.S. public health and medical guidelines describe providers' professional and ethical obligation to offer pregnant patients information for all pregnancy options, and this practice is associated with higher patient satisfaction. However, pregnancy options counseling practices vary across settings.  Standardized practice can help reduce variation and systemic bias. Twenty-two EWG members agreed to this recommendation in 2024.

Learn more: Section 8. Pregnancy Testing and Counseling

6. Person-Centered Contraceptive Service Delivery (updated)

Recommendation: A person-centered contraceptive care approach can help providers ensure that people are offered contraception services that are in alignment with their individual values, preferences, needs, and desires. This includes using quality contraceptive counseling techniques and offering information about and access to a full range of hormonal and non-hormonal contraceptive options, including permanent methods, either at a service delivery site or by referral.

Quality of evidence: A systematic review was conducted that focused on contraceptive counseling, education, and care.23, 24 The recommendation was made on the basis of findings from the systematic literature review and expert opinion. Of 61 studies that were identified in the systematic review, 39 looked at patient-specific outcomes related to experiences, preferences, barriers and facilitators with mixed designs (20 qualitative, eight cross-sectional, five systematic literature reviews or scoping reviews, three randomized controlled trials, one quasi-experimental design, one cohort study, and one mixed-methods study). Twenty-six studies described patient preferences for how they want to receive contraceptive counseling, education, and care. The recommendation was also supported by reviews of other U.S. public health and medical guidelines (for example, CDC, WHO, ACOG, Society of Family Planning) and expert opinion.

Potential consequences: Consequences might include increased patient satisfaction with services, increased patient participation in care and sense of autonomy, and increased patient ability to access and use their preferred method and switch or discontinue their method when desired.

Rationale: Grounded in a person-centered contraceptive care approach, the steps for contraceptive care delivery outlined in this section are supported by a substantial body of evidence and expert opinion. This approach is a shift from traditional models of contraceptive care delivery that focused on attributes of contraceptive methods, particularly effectiveness, to guide counseling and encourage method uptake. Person-centered care requires providers to put aside their assumptions and opinions about what they believe is best for the patient to identify and center their patients’ preferences for contraceptives based on their own goals and values. There is no “best” method of contraception for everyone, nor is the success of care defined by contraceptive uptake and use. People have many reasons why they may choose not to use a contraceptive method, to use less effective strategies for pregnancy prevention, or to use birth control methods for reasons other than contraception, including for gender-affirming care. Twenty-two EWG members agreed to this recommendation in 2024.

Learn More: Section 5. Person-Centered Contraceptive Care Delivery

7. Screening and Other Preventive Health Care Services (updated)

Recommendation: Health care visits should include provision of or referral to other preventive health services, including screening for healthy weight and chronic medical conditions (for example, diabetes, and hypertension); screening for immunization status; screening for genital tract and breast cancer; providing gender-affirming care; and discussing topics such as perimenopause, mental health, use of alcohol and other substance use, sexual assault, intimate partner violence, and human trafficking to improve the health of individuals and communities. When screening results indicate the presence of a health condition, the provider should take steps either to provide or to refer the person to further diagnostic testing and treatment as appropriate. Services should be provided in a manner that is consistent with established federal and professional medical associations’ recommendations to enable patients who need services to receive them and to avoid over-screening.

Quality of evidence: An environmental scan on guidelines was conducted. The recommendation was made on the basis of reviews of other relevant guidelines and opinions developed by the federal government and medical associations (for example, the CDC, USPSTF, ACOG, ASRM, and the American Academy of Child and Adolescent Psychiatry) and expert opinion.

Potential consequences: More individuals will receive preventive health services, which might improve their health and health-related knowledge. There is a risk of over-screening if recommendations are not followed. There is a potential risk that a patient with a positive screening test will not be able to afford further diagnostic evaluation and treatment if the patient does not have insurance coverage. The human and financial cost of providing preventive health services might mean that fewer SRH services can be offered.

Rationale: The 2014 version of the QFP recommended a suite of primary care services to promote the health of individuals before conception. This document aims to move beyond the notion of primary care services for the promotion of healthy pregnancy and birth by recommending all individuals, regardless of pregnancy intention, be offered primary care services. The TEP and EWG thought potential benefits to the health of individuals were greater than the costs (including opportunity costs) and potential harms of providing these services. Implementation (for example, training and monitoring of providers) can address the issues related to providers over-screening and not following the federal and professional medical recommendations. Twenty-two EWG members agreed to this recommendation in 2024.

Learn More: Section 6. STI and HIV Services and Section 10. Screening and Other Preventive Health Care Services 

8. Using Performance Measures to Track and Improve Quality of Care (updated)

Recommendation: Sites that offer SRH services should develop performance measurement and quality improvement processes that are person centered, avoid creating harm, allow for evaluation of inequities, and include the intentional dissemination of results. Service sites should select, measure, and assess at least one intermediate or outcome-based performance measure on an ongoing basis. Performance data should be shared widely with facility staff at all levels and across all disciplines. Once the measures have been incorporated into data collection and review processes, service sites can identify opportunities for improving care quality.

Quality of evidence: A new systematic review was not conducted, but the recommendation was made on the basis of a systematic review on quality improvement referenced in the 2014 QFP report; guidance and guidelines developed by the federal government and nongovernmental organizations (for example, CMS, the Health Resources and Services Administration [HRSA], the Women’s Preventive Services Initiative [WPSI], and the Partnership for Quality Measurement [PQM]); an environmental scan OPA conducted for this update, focused on performance measures for improving select SRH services; and expert opinion.

Potential consequences: More service sites will identify and implement measures to improve patient care and outcomes, reduce costs, increase efficiency of care delivery, and monitor success at satisfying regulatory requirements. It was also noted that performance measures can, in some cases, adversely impact outcomes and patient experience by incentivizing specific behaviors or processes inconsistent with person-centered care. Balancing measures that reflect experience of care and people’s lived experience can help protect against these effects.

Rationale: A growing body of research has demonstrated that performance measures are used widely to drive quality improvement; help find weaknesses; prioritize opportunities; and identify, track, and address inequities. In addition, quality performance metric reports offer an opportunity for providers to compare their performance to that of their peers, which has been shown to motivate providers with lower performance scores to modify their practices to improve quality. The recommendations in this chapter are consistent with those made by national leaders in the performance measurement and quality improvement fields. The examples of performance measures align with the original QFP recommendations, CMS’ core set of Adult and Child Health Care Quality Measures, and the approved and HRSA-supported WPSI recommendations. This list includes a core set of validated contraceptive care performance measures that have been endorsed since the original QFP was published. Twenty-two EWG members agreed to this recommendation in 2024.

Learn more: Section 11. Using Performance Measures to Track and Improve Quality of Care

9. Contraceptive Services – Availability of a Broad Range of Methods (retained)

Recommendation: SRH programs should offer and stock a broad a range of FDA-approved or FDA-cleared contraceptive products and provide counseling and education on the use of natural family planning methods so the needs of individual patients can be met promptly. These methods should be available at service delivery sites, but strong referral networks can facilitate efforts to make methods not available on-site real options for patients.

Quality of evidence: No new research was identified that explicitly addressed the question of whether having a broad range of methods was associated with short-, medium-, or long-term reproductive health outcomes. Rather, outcomes in the new research focused on patient and provider experiences and preferences. However, three descriptive studies from the review of quality improvement literature identified contraceptive choice as an important aspect of quality care. A systematic review was conducted that focused on contraceptive counseling, education, and care, including barriers and facilitators patients and providers experience.23, 24 Of 61 studies identified in the systematic review, 14 looked at patient-specific barriers and facilitators with mixed designs (10 qualitative, two synthesis, one cross-sectional, and one mixed methods) and nine looked at provider barriers and facilitators with mixed designs (seven qualitative, one cross-sectional, and one systematic literature review).

Potential consequences: Consequences might include increased access to contraception and use of reproductive health services. Patients will be more likely to select their preferred method, and it will be easier to switch their method when desired. It also was noted that there are sometimes high costs to stocking certain methods (for example, IUDs and contraceptive implants).

Rationale: Having a broad range of promptly available contraceptive methods is central to person-centered care, a core aspect of providing quality services. Individual patients need to have a choice so they can select a method that best fits their particular circumstances. This is likely to result in more correct and consistent use of the chosen methods. The benefits of this recommendation were seen as exceeding the negative outcomes (for example, additional cost). All EWG members agreed to this recommendation in 2014. Twenty-two EWG members agreed to this recommendation in 2024.

Learn More: Section 5. Person-Centered Contraceptive Care Delivery

10. Youth-Friendly Services (retained)

Recommendation: SRH programs should take steps to make services "youth-friendly," defined as services that are accessible, acceptable, equitable, appropriate, and effective for adolescents.

Quality of evidence: Of 20 studies that were identified in 2014 for the original QFP, six looked at short-, medium-, or long-term outcomes with mixed designs (one group time series, one cross-sectional, three prospective cohort, and one nonrandomized trial); protective effects were found on long-term (two of three studies), medium-term (three of three), and short-term (three of three) outcomes.3

Potential consequences: Consequences might include increased use of reproductive health services by adolescents, including contraception and STI screening, testing, and treatment; and greater satisfaction with services. It is also likely to enhance SRH knowledge among adolescents. It is possible there will be higher costs. The EWG noted some uncertainty regarding the benefits due to the relatively weak evidence base when this evidence was reviewed in 2014.

Rationale: Existing evidence has demonstrated the importance of specific characteristics to adolescents’ attitudes toward and use of clinical services. The potential benefits of providing youth-friendly services outweighed the potential costs and the weak evidence base at the time the 2014 QFP report was published. All EWG members agreed to this recommendation in 2014. Of note, some said that it should be cast as an example of comprehensive patient-centered care, rather than an end of its own, which aligns with the revised approach taken in 2024. Twenty-two EWG members agreed to this recommendation in 2024.

Learn more: Section 3, Exhibit 4. Providing Adolescent Care