A systematic, Web-based review of publicly available information on federal and territorial programs with policies that facilitate access, delivery, and utilization of contraceptive coverage and family planning services in Puerto Rico between 2015 and 2018 was conducted from March to June 2019. Available legislation, statute and regulations, reports, and other territorial health or other agency-published documents were identified for data extraction using Google and examined for inclusion. We applied a standardized search strategy of multiple search terms based on contraception and family planning relevant themes related to territorial health or other agencies, government funding sources, entitlement programs, and Zika virus emergency response efforts, as well as professional associations or research/policy organizations that may describe relevant programs on their Web site (see Table, Supplemental Digital Content 1, summary of search terms, available at http://links.lww.com/JPHMP/A774). All identified documents published by federal or territorial agencies or government were examined for inclusion in the study. Documents that did not specifically address territorial contraceptive coverage and family planning services policies were excluded. All documents addressing territorial policies contraceptive coverage and family planning services were abstracted for in-depth review and summarization.

The abstracted data were reviewed to identify language that included contraceptive coverage and payment policy. Information was searched separately and simultaneously by 2 abstractors (F.V.A and L.R.). Each abstractor then independently cross-referenced the search findings of the other, completing double-data entry of source information. Discrepancies were reconciled among the abstractors to ensure consistency in search strategy, data entry, data coding, and variable definitions. Information abstracted included (1) policy source(s) (eg, Medicaid State Plan Amendment, regulations governing federal programs), (2) verbatim text of the policy, (3) summary of the policy text, and (4) date the policy was enacted. Variables were coded as not specified when there was no specific language in the policy text that clearly met the defined variable category. Following the validation, study authors (F.V.A and L.R.) reviewed and created a summary of abstracted data related to contraceptive coverage and payment policy and contraceptive access policy and practice change during the Zika virus outbreak. Programs with identified policies were reported and variations described.

Semistructured interviews were conducted with key stakeholder groups in Puerto Rico to understand perceptions of policy and practice change efforts to improve contraception access in Puerto Rico following the Zika virus outbreak. An interview guide was developed and individuals from key stakeholder groups were identified to participate in a phone or in-person semistructured interview between May and August 2018.

A convenience sample was used to identify individuals from key stakeholder groups that represented decision makers, implementers, and end users of federal and territorial programs with policies that facilitate access, delivery, and utilization of contraceptive coverage and family planning services. A total of 9 semistructured interviews were conducted among the 3 key stakeholder groups. Decision makers (n = 3) were defined as individuals who held, or recently held, a position in a local government agency that could effect change to contraceptive coverage and family planning services in Puerto Rico. Implementers (n = 3) were identified as individuals in leadership positions within local government agencies, nongovernmental organizations or community health clinics tasked with putting into practice the mandates, or the requirements of policies related to the provision of contraceptive services. The end users (n = 3) were local physicians who provided contraceptive services and family planning patients. Prior to the interview, participants consented to participation and were informed that they could cease participation at any time. The semistructured interview was not recorded to protect confidentiality; however, detailed notes were taken by the interviewer. The notes were transcribed in Spanish and later translated into English.

The semistructured interview questions were organized into 3 domains: (1) emergency response efforts to improve contraception access; (2) local efforts to improve contraception access; and (3) policy efforts to improve contraception access. Each domain included questions to document key stakeholders’ perceptions of barriers and facilitators specific to health systems change efforts during and after the end of the Zika virus outbreak in Puerto. Interview notes were systematically coded to identify barriers and facilitators for contraception access and provision of contraceptive services in Puerto Rico. Thematic analysis was used to organize the information into the 3 domains. The CDC determined the review of policy data and the semistructured interviews to be nonresearch public health practice.

Our review identified that between 2015 and 2018, federal and territorial programs with publicly available policies related to contraceptive services in Puerto Rico included the following: Medicaid,¹⁰ National Title X Family Planning program (Title X),¹¹ Health Resources & Services Administration (HRSA) Bureau of Primary Health Care’s Health Center Program,¹² and the Z-CAN program ¹³ (Table 1).

Medicaid, Title X, and the Health Center Program policy documents described that federal funding was used for family planning services in Puerto Rico (Table 1). The Z-CAN did not use federal funding for the provision of family planning services; philanthropic and private sector partnerships were mobilized to secure resources to make contraceptive services, including client-centered contraception counseling and contraception methods, available at no cost across the territory during the Zika virus outbreak.¹⁴ All programs had policies that described providing the full range of Food and Drug Administration–approved contraceptive methods; however, the provision of LARC methods was limited among Medicaid, Title X, and the Health Center Program (Table 1). In 2015, the Puerto Rico Medicaid State Plan Amendment expanded services to include at least one of every class and category of Food and Drug Administration–approved contraceptive methods¹⁰; however the copper intrauterine device (IUD) was the only LARC method on the Medicaid formulary.¹⁵ Title X required grantees to offer a broad range of acceptable and effective medically approved contraceptive methods¹¹; however, prior to the Zika outbreak, the Title X grantees in Puerto Rico provided limited LARC methods (mainly copper IUD and no contraceptive implant).¹⁶ The Health Center Program provided obstetrics, gynecology, and voluntary family planning services,¹² including counseling on available family planning options and management/treatment as appropriate for a patient’s chosen method.¹² The Z-CAN provided the full range of reversible contraceptive methods for nonsterilized women of reproductive age during the Zika virus outbreak in Puerto Rico (Table 1).¹³

Logistical or administrative approval, including referral, prior authorization, or cost sharing, was required by Medicaid (Table 1). Medicaid required a referral to 1 of 13 family planning clinics contracted to provide contraceptive services from the Medicaid-managed care organizations.¹⁷ In addition, prior to the Medicaid referral for contraceptive services, prerequisite diagnostic testing for first visit, including pregnancy, sexually transmitted disease, human immunodeficiency virus, and Papanicolaou (Pap) test, was required.¹⁸ Title X, the Health Center Program, and Z-CAN did not report any required logistical or administrative approval for contraceptive services (Table 1).

All programs reported a policy that covered screening for pregnancy intention and provision of contraceptive counseling (Table 1). In addition, all programs reported a policy that LARC methods were reimbursed at the actual cost of the device; however, Medicaid reported reimbursement for the only LARC device (copper IUD) on the Medicaid formulary (Table 1). Title X reported a schedule of fees designed to recover the reasonable cost of providing services,¹⁶ and the Health Center Program reported that care was provided on the basis of a sliding fee scale and ability of patients to pay for services.¹² The Z-CAN provided all LARC methods (levonorgestrel-releasing IUD, copper IUD, contraceptive implant) at no cost to patients who participated in the program. All payors reported a policy that covered LARC supplies, insertion and removal procedures, and follow-up care (Table 1). Furthermore, Z-CAN reported a policy that covered postpartum LARC supplies, procedure, and follow-up; Title X did not have a policy as Title X services include outpatient services only and the Health Center Program did not specify. Finally, Title X, Health Center Program, and Z-CAN all had policies that provided provider training (eg, client-centered contraceptive counseling, LARC insertion, removal, and management)^11,13; Medicaid did not specify¹⁰ (Table 1).

All programs reported policy and practice change strategies to increase access to or provide contraceptive services following the Zika virus outbreak (Table 2). The Puerto Rico Secretary of Health issued Administrative Order 350 to broaden access to contraceptive methods during the Zika virus outbreak by acknowledging that Zika virus is a cause of serious birth defects in infants resulting from Zika infection during pregnancy; educating providers about the prevention of adverse outcomes associated with Zika and training providers on the insertion, removal, and management of LARC; establishing a plan to expand access and coverage to effective contraceptive methods, including implant, IUDs, oral contraceptive pills, injectable, vaginal ring, patch, and condoms; and requiring all public and private insurers under the jurisdiction of the Insurance Commissioner and the Puerto Rico Health Insurance Administration (ASES) to disclose and issue plans for execution of the order.¹⁹ In addition, the Commissioner of Insurance issued a letter to support Administrative Order 350 and request compliance by health insurers to broaden their contraceptive methods coverage during the Zika virus outbreak.²⁰ As a result of the identification of administrative and logistical barriers, the National Title X Family Planning program expanded coverage of LARC methods and trained Title X physicians and staff on client-centered contraceptive counselling and LARC insertion and removal, both of which continued after the Zika outbreak (Table 2). The Health Center Program, in partnership with Z-CAN, trained physicians and staff on client-centered contraceptive counseling and LARC insertion, removal, and management. Forty community health centers participated in Z-CAN to increase contraceptive access points across Puerto Rico. Finally, the Z-CAN program provided the full range of reversible methods to women at no cost, trained physicians and staff from private practices, community health centers, academic clinics, and public health clinics across all 5 public health regions in Puerto Rico on client-centered contraceptive counseling and LARC insertion, removal, and management and proctored Z-CAN physicians posttraining to ensure competency in delivering high-quality contraceptive services.¹³ The Z-CAN also increased public and private contraceptive access points from 13 publicly funded sites to 139 public and private sites, provided bundled reimbursement for LARC insertion and removal to ensure no-cost LARC removal after program ended, and educated women about the safety and efficacy of the full range of contraceptive methods and offered women the choice of methods that best met their reproductive health needs.^7,8 Furthermore, Z-CAN worked with federal and territorial partners to sustain high-quality contraceptive services after the program ended (Table 2).^7,8

Perceptions of decision makers, implementers, and end users about health systems change efforts following the Zika virus outbreak were reported (Table 3). All key stakeholders reported that Puerto Rico had policies prior to the Zika virus outbreak that supported public and private health insurance coverage of contraceptive services; however, implementers perceived limited implementation of the policies specific to the availability of the full range of reversible contraceptive methods and dissemination of information to the end users. Key stakeholders reported that the emergency response to the Zika virus outbreak supported an environment to develop and implement, through Z-CAN, a series of short-term policy and practice changes to improve contraceptive services in Puerto Rico (Table 3). The identified policy and practice changes included forming a multisector collaboration between federal agencies, territorial government agencies, private corporations, and domestic philanthropic and nonprofit organizations to expand access to full range of reversible contraceptive methods, including methods not readily available to women in Puerto Rico, at no cost to women of reproductive age, regardless of age, income, or insurance status. Among local efforts, decision makers and implementers identified facilitators through the Administrative Order 350, which recommended that insurers and health insurance organizations broaden access to contraceptive methods during the Zika virus outbreak emergency (Table 3). Furthermore, the 2004 Puerto Rico Pharmacy Act²¹ and a subsequent amendment (Public Law 95–2014) in 2014²² require all physicians to obtain a medical office drug cabinet license to purchase, store, and administer medications in their respective offices but only for immediate use by patients at the physician’s office and not for future use by the patients. Given this requirement impacts the stocking and dispensing of contraceptive methods, including oral contraceptive pills, patch, and ring, the territorial government agency provided a temporary waiver to Z-CAN physicians to allow stocking and dispensing of all contraceptive methods in their clinics, hence facilitating same-day access. End users indicated that Z-CAN also addressed barriers, such as lack of trust and misinformation by patients about contraception, and training gaps in client-centered contraceptive counseling and LARC insertion, removal, and management (Table 3).