This is a collection of questions about providing family planning services during the COVID-19 pandemic with corresponding evidence-based answers and the current advice at this time. Family planning providers should use the Interim CDC Guidance on Handling Non-COVID-19 Public Health Activities to plan for services. Beyond continuing to provide accessible, high-quality, client-centered family planning services, the overriding objective in providing answers to these questions is to promote physical distancing; that is, keeping in-person visits to a minimum to protect both clinic staff and clients from becoming infected with SARS-CoV-2 virus and acquiring COVID-19 infection. Since the mitigation strategies recommended by CDC guidance includes limiting face-to-face interactions to only the most essential, this document assumes that clinics will have converted most or all client interactions from in-person visits to virtual visits, and utilizing curbside pick-up or mail to deliver contraceptives and other supplies.
Most of the references cited here were published before March, 2020, and therefore do not provide specific advice regarding how certain practices can be modified or deleted in response to this public health emergency. Family planning providers should use this information to develop or modify their local clinic protocols, ideally including clinical staff members who will be providing client care, remotely or in-person. In some cases, clinic staff will have to balance the benefit of physical distancing against the potential risk of adopting less traditional approaches to care. It is important to keep in mind that some of these modifications will be temporary and will be reversed once the public health emergency is no longer present, while others may remain and change practice for the better.
The questions and answers have been categorized in the same format as Providing Quality Family Planning Services: Recommendations of the CDC and the U.S. Office of Population Affairs (OPA). FPNTC will update this resource frequently to address additional questions as more information becomes available and public health priorities evolve during the pandemic. Please send questions to firstname.lastname@example.org. Title X grantees should consult with their OPA Project Officer to ensure practice modifications comply with Federal regulations.
Combined hormonal contraceptives, progestin-only pills
How can family planning providers obtain blood pressure (BP) when the provider is offsite?
BP measurement is necessary because hypertension is one of five risk factors for acute myocardial infarction (heart attack) in women using estrogen-containing hormonal methods (the other four are older age, heavy smoking, diabetes, and abnormal lipid levels [low HDL, high LDL, or high triglycerides]). If a client has more than one risk factor, the risk of a heart attack increases with each. For combined hormonal contraception (CHC)—including oral contraceptives (OC), patch, ring—The U.S. Medical Eligibility Criteria for Contraceptive Use (MEC) classifies multiple risk factors for atherosclerotic cardiovascular disease as MEC Category 3/4, depending on the individual client’s history. In addition, severe hypertension (systolic >160 mmHg or diastolic >100 mg Hg) or hypertension with vascular disease are MEC Category 4.
The U.S. Selected Practice Recommendations for Contraceptive Use (SPR) states that BP “should be measured before initiation of CHCs. In instances in which BP cannot be measured by a provider, BP measured in other settings can be reported by the woman to her provider” (p. 24). Subsequently, at the time of other routine follow-up visits, assessment of BP is recommended, but again the SPR states that “BP measurement in other settings is acceptable” (p. 27). Other settings may include BP measured on a home monitor or using a BP machine at a local pharmacy.
If a client has a recorded normal BP in the system’s electronic medical record in any clinical setting (for instance if they saw a provider for a different reason), that reading can be used. The current USPSTF recommendation is: “Adults aged 18 to 39 years with normal blood pressure (<130/85 mm Hg) who do not have other risk factors should be rescreened every 3 to 5 years,” which provides an outer time limit for use of the last BP reading.
Some clinics have implemented a policy whereby if a client wants to start a CHC and has no cardiovascular risk factors, she can be given a prescription (or supplies for curb-side pick-up) of 3 cycles of OCs, patch or ring, postponing an in-person BP measurement until after the public health emergency has ended. Others have developed the ability to have the client drive to the clinic parking lot, be given a home BP machine with a recordable read-out to be used in their car, then returned to staff using appropriate PPE.
Finally, if it is not possible to get a BP reading, consider offering the client a non-estrogen-containing contraceptive method until the client’s BP can be measured and documented.
What options can family planning providers offer clients who are due for their depot medroxyprogesterone acetate (DMPA) shot to avoid a clinic visit?
DMPA can be administered in two ways: intramuscularly (IM) 150 mg or subcutaneously (-SQ or sub-Q) 104 mg. They are equally effective, with a typical use failure rate of 4 pregnancies per 100 women per year. DMPA 150 IM is available in both brand name and generic versions; DMPA-SQ is available only as a brand name product (depo-subQ provera 104®).
According to SPR, DMPA is given every 13 weeks but is effective for up to 15 weeks. If DMPA 150mg IM injections are not available in-person or as a curbside service (with the client being injected while in her car), she can either get a prescription for another method until restarting DMPA 150mg IM or consider switching to the self-injected DMPA-SQ.
DMPA-SC 104 is a good choice for clients who are experienced in self-injection (e.g., fertility drugs to induce ovulation, insulin, or a drug for multiple sclerosis) or who are willing to learn how to self-inject this product. It can be used by clients who currently receive DMPA 150 mg IM every 13 weeks who want to switch to this delivery route or can be used by clients new to DMPA.
While depo-subQ provera 104 is not FDA-labeled for self-injection, studies have demonstrated the safety and feasibility of self-administered DMPA SQ.1,2, Given current FDA labeling states that "Depo-subQ provera 104 is only for subcutaneous administration and is only to be administered by a healthcare professional," prescribing it to a client for self-injection is an “off-label” use. Providers should use their clinical judgement to determine whether this method of delivery is appropriate for the client, and should document their rationale.
How can family planning providers train clients for DMPA-SQ injections? Does it have to be by telemedicine?
Ideally, clients who initiate this method should receive instruction in the self-injection technique by a synchronous audio/video telehealth visit. If this is not possible, the client should be referred to a training resource for step-by-step instruction. Example training resources include:
- Detailed package insert instructions
- Bedsider.org: Depo SubQ: The do-it-yourself birth control shot
- Reproductive Health Access Project: Depo-Provera Sub-Q User Guide (available in English, Spanish, Simplified Chinese, Traditional Chinese, Hindi, Vietnamese)
Can family planning providers order DMPA-subQ 104 to a local pharmacy?
Yes. Many pharmacy chains list DMPA-SQ as an available product. However, call the pharmacy in advance to find out if it is in stock, and if not, how long it will take the pharmacy to make it available. Always check to see if this product is on the formulary of the client’s health plan. If not, full price out-of-pocket costs with programs such as GoodRx.com is about $250.00. Some pharmacies will mail or deliver the product to the client’s home or offer curbside pick-up.
1 Dragoman MV, Gaffield ME. The safety of subcutaneously administered depot medroxyprogesterone acetate (104mg/0.65mL): A systematic review. Contraception. 2016 Sep; 94(3):202–15.
2 Beasley A, White KO, Cremers S, Westhoff C. Randomized clinical trial of self-versus clinical administration of subcutaneous depot medroxyprogesterone acetate. Contraception. 2014 May; 89(5):352–6.
IUDs and Implants
Can family planning providers still safely provide intrauterine devices (IUD) and implants?
Yes, some family planning providers are continuing to offer IUDs and implants to meet clients’ pregnancy prevention needs. It is one of the few family planning services for which it may be appropriate to provide an in-person visit. Family planning providers should use the Interim CDC Guidance to make decisions about face-to-face activities depending on the local level of community transmission or impact of COVID-19.
Consistent with the Interim CDC Guidance, for any face-to-face activities, providers should implement symptom screening and triage patients before they come to the clinic, provide face masks to patients upon arrival, utilize physical distancing strategies to limit contact with patients at triage, emphasize hand hygiene, and provide appropriate PPE for staff‘s role. All health care staff and providers, as well as the client, should wear surgical masks during IUD and implant placements and removals. The reason for the client to don a mask is to protect the providers and staff in the room if she has incubating or pre-symptomatic COVID-19, as well as protecting herself from infection during a procedure where the rules of physical distancing from providers and staff can be difficult to achieve. See Beyond the Pill’s LARC Guidance During COVID-19 for more information.
A pre-visit telemedicine visit should occur where an initial screening is done to: a) determine whether the client is currently or has recently had symptoms suggestive of COVID-19 infection, if anyone they have been in contact with has been symptomatic, or if they or anyone they have been in contact with has been confirmed as having COVID-19, and (b) take care of any administrative needs as well as conduct counseling, education, answer questions. During the televisit, the provider should confirm with reasonable assurance that the woman is not pregnant and even assist the woman with taking a pregnancy test, if appropriate. This will help make the in-person visit as efficient as possible, thereby limiting exposure time.
What can family planning providers tell clients who ask about expired IUDs and implants?
There is evidence that IUDs and implants are likely to be effective longer than their FDA-approved duration. Summarized by the Reproductive Health Access Project, evidence-based duration is as follows:
|FDA-Approved Duration||Evidence-Based Duration|
|Nexplanon||3 years||5 years|
|Liletta||6 years||7 years|
|Mirena||5 years||7 years|
|Skyla||3 years||3 years|
|Kyleena||5 years||5 years|
|Paragard||10 years||12 years|
|DMPA||12 weeks||15 weeks|
If the IUD or implant truly has expired, even by the extended evidence-based duration, providers should:
- Reassure that leaving the method in beyond its expiration will not cause harm (i.e., the IUD does not need to be removed emergently once it has expired, as long as no warning signs are present).
- Prescribe another method until in-person services resume and the IUD can be exchanged.
- Advise and counsel clients to use condoms.
Should family planning providers still provide emergency contraception (EC)?
Yes. EC should still be provided. Recommendations regarding the use of levonorgestrel ECPs (LNg, Plan B®) and ulipristal acetate (UPA; Ella®) are unchanged, remembering that UPA is more effective than LNg ECPs 72-120 hours after unprotected intercourse and in women whose body mass index is 26 kg/m2 or higher. Given the time-sensitivity of this service, curbside pick-up or transmission of the prescription to a pharmacy for same-day pick-up is optimal. Consider providing counseling and offering a contraceptive method that can be obtained at the time of ECP pick-up.
Can family planning providers still offer the copper IUD for EC?
Yes. Although it may be more difficult to arrange for an in-person visit for placement of a copper IUD, this method is the most effective form of EC. See the section on IUDs and implants for information on recommended safety measures for the provision of a copper IUD as EC.
How can a client with a vaginal discharge or vulvar irritation be evaluated remotely?
If a client is having a recurrence of a vulvovaginal condition that was previously diagnosed, she can be offered treatment based on a telephonic or telemedicine visit.
For a new problem, obtaining a thorough history and conducting an assessment via telehealth can allow the provider to consider empiric treatment for vaginitis. For example, if the client has a malodorous vaginal discharge suggestive of bacterial vaginosis or trichomoniasis, metronidazole 500 mg orally twice a day for 7 days will treat either condition.
If they have vulvar irritation/itching and white, cottage-cheese like discharge, the client could be treated empirically with fluconazole 150 mg orally in a single dose, or could self-treat with over-the-counter antifungal products for vaginal yeast.
Some clinics have used curbside for pick-up and drop-off of vaginal discharge sampling kits, which include a stoppered-plastic or glass tube filled with 1 cc of fresh saline solution and a pack of sterile cotton tipped swabs. The client should be instructed to swab her vaginal walls to obtain a sample, immediately place the swab into the tube and cap it, then to drop it off at the clinic as quickly as possible for microscopic evaluation, given that trichomonads will live briefly in a light-filled aerobic environment.
If a client is having an episode of recurrent genital herpes, they can be offered treatment based on a telephonic or telemedicine visit.
Some clients may be willing to take a cell phone photograph of their genital skin rash and submit it to the clinician, given that it is a variant of the established practice of teledermatology. (Note: Many payers include this service, using a virtual check-in code, G2010, “Remote evaluation of recorded video and/or images submitted by an established client (e.g., store and forward), including interpretation with follow-up with the client within 24 business hours.”)
Can family planning providers treat clients with possible gonorrhea or chlamydia contact without an in-person visit?
If the client has had sexual contact with a person known or suspected to have chlamydia, gonorrhea, or both, and diagnostic testing is not a possibility, empiric therapy for both pathogens is an acceptable alternative. This is true regardless of whether the client is presenting with symptoms or not, and regardless of the client’s gender identity of the gender of their sex partners.
If in-person injections are not a possibility, CDC recommended treatments including cefixime 800 mg orally and azithromycin 1 gram. This is a change from the 2015 CDC STD Treatment Guidelines, which previously recommended 400 mg of cefixime. If azithromycin is not available and the client is not pregnant, doxycycline 100 mg orally twice a day for 7 days is recommended. Additional recommendations on treatment of sexually transmitted diseases (STD) from CDC can be found in the CDC STD Division of STD Prevention guidance and summarized in this table.
Can family planning providers use expedited partner therapy (EPT) for gonorrhea or chlamydia treatment?
Yes, EPT can be made available to a partner(s) either by writing a prescription in the name of the partner or doubling the dose of the medications dispensed to the client. These approaches are even more critical during this public health emergency to avoid needing to see a client, or partners, during a face-to-face visit. For more detail, including links to state laws regarding EPT, refer to current CDC EPT guidelines.
Can family planning providers use at-home test kits for STDs as an alternative to in-clinic sampling?
There is a difference between at-home sampling and at-home screening test kits. At-home sampling can be done by at-home self-sampling of vaginal fluid or urine collection and in some cases, rectal or pharyngeal swabs with the same collection technique used in the clinic, then transported back to the clinic for curbside drop-off or to a contracted lab test-deposit site.
At-home STD screening test kits are either point-of-care tests, with an immediate result, or self-sampling with the specimen mailed to a commercial lab. These typically are sold directly to consumers or through on-line telehealth companies. More information about the options and how to use them can be found on KFF's site.
The types of tests offered vary from company to company, but often include HIV, GC/CT, syphilis, trichomonas. Some companies also offer throat/rectal swabs for GC/CT, as well as blood spot tests for syphilis and hepatitis C.
Do insurance companies pay for at-home sampling or at-home screening test kits?
It depends. Health insurance companies pay claims for laboratory tests based on whether the CPT code of the test is a covered benefit and performed in a contracted lab. If the client picks up a collection kit and lab slip for a test (ideally by curbside delivery), self-samples at home, drops off the test kit (with the lab slip) curbside at the clinic or lab office, and then has the same test run that she normally would have had, it should be covered.
If the CPT code for an at-home test kit is not a benefit of the payer, or if the test is run by a non-contracted lab, it is unlikely to be covered. Look up whether the CPT code of a lab test is a benefit of the client’s payer; if this information is not available online, then it is best to contact the health plan to find out. Equally important is determining whether the lab running the test is contracted with the health plan. Some PPO health insurance plans cover the costs of telehealth visits, medications, and at-home STD screening tests through online telehealth companies.
Can Title X family planning providers accept the results of pregnancy tests performed by the client at home?
Yes. OPA has given guidance: “As long as the state of emergency exists, any services that [Title X agencies are] able to provide under normal circumstances that you can provide through telehealth will be considered Title X services.”
Does Medicaid accept results of at-home pregnancy tests to determine eligibility for Medicaid during pregnancy?
There is no national guidance from the Centers for Medicare & Medicaid Services (CMS) on this, so it is up to each state to determine their own criteria for pregnancy verification. Family planning providers should check the website of their state Medicaid programs to check on whether Medicaid has modified their policies to permit a home pregnancy test to be the sole determinant of pregnancy, as opposed to still requiring a clinic visit and clinician verification of pregnancy.
Can family planning providers continue to provide services to help clients achieve pregnancy during COVID-19?
Family planning providers can continue to provide services to help clients achieve pregnancy, including basic infertility services using telehealth. For example, family planning providers can provide counseling on fertility awareness and preconception health.
Though prenatal care services are outside the scope of Title X, Title X providers are required to refer for medically necessary prenatal care. The American College of Obstetricians and Gynecologists (ACOG) has issued comprehensive and detailed guidelines regarding the timing and content of prenatal care visits. They can be found in COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics.
In addition, ACOG and the Society for Maternal Fetal Medicine have developed an algorithm for the Outpatient Assessment and Management for Pregnant Women with Suspected or Confirmed Novel Coronavirus (COVID-19).
What advice should family planning providers provide regarding sexual practices during the pandemic?
There are no evidence-based national guidelines on this subject yet, which makes counseling and health education difficult. What is known is that COVID-19 is spread by saliva droplets, which are likely to be exchanged during sexual intercourse. According to research out of China released on May 7th in the Journal of the American Medical Association, SARS-CoV-2 has been detected in the semen of men with acute infection and those that are recovering from infection. The independent contribution of the virus in semen is unclear as there are also respiratory droplets and saliva that are often exchanged during sex. Based on small studies out of China among women with severe COVID-19 illness, SARS-CoV-2 is not detectable in vaginal fluid.
Can family planning providers continue to provide the second or third doses of HPV vaccines?
National guidelines imply that the second or third doses are not time-sensitive and that administering them can be postponed until after the public health crisis. The CDC Pink Book states: “There is no maximum interval between doses. If the HPV vaccine schedule is interrupted, the vaccine series does not need to be restarted. If the series is interrupted after the first dose, the second dose should be given as soon as possible, and the second and third doses should be separated by an interval of at least 12 weeks. If a third dose is indicated and only the third dose is delayed, it should be administered as soon as possible.” The Immunization Action Coalition also states that the HPV vaccine series does not need to be restarted because of an interval that is longer than recommended. Providers should continue the series where it was interrupted.
How should family planning providers manage women who were found to have abnormal cytology results?
Given that progression through the stages of cervical dysplasia is a very slow process over the course of years for most women, family planning providers may want to reschedule colposcopic evaluation and follow-up visits until the time that face-to-face office visits are resumed. The American Society for Colposcopy and Cervical Pathology (ASCCP) have issued the following ASCCP Interim Guidance during COVID-19 Pandemic:
- LSIL: postpone diagnostic evaluations up to 6–12 months
- HSIL, ASC-H: documented attempts to contact and diagnostic evaluation scheduled within 3 months
- High-grade cervical disease without suspected invasion
- Documented attempts to contact and procedures scheduled within 3 months
- Suspected invasive disease
- Contact attempted within 2 weeks and evaluation within 2 weeks of that contact (4 weeks from the initial report or referral)
What services are family planning providers delivering virtually (i.e., via telehealth)?
Everything, except IUD and implant placements and removals can be provided virtually. The shared decision-making client-centered counseling can be done remotely, following which the client may come to the service site for the procedure, if in-person services are being offered.
Should family planning providers consider "hybrid" televisits in which providers are doing the televisits from home and clients are at the center for labs and blood pressure checks with a nurse or medical assistant?
Hybrid visits can be an effective way of meeting client needs while also limiting their time in the clinic. The provider/program can determine whether hybrid visits are an option at their site and under what circumstances. However, this approach may involve more in-clinic presence than is necessary. Non-clinic alternatives for BP checks are listed above, and many test sampling kits can be done by curbside pick-up. Blood draws, if necessary, can be done at a laboratory satellite site if it is more convenient than a clinic. The approach should be tailored to the specific circumstances of the community.
Are there national guidelines on a preferred method of prioritizing visit types according to which should be done in-person, virtually (i.e., telehealth using audio only or audio and video), or postponed?
The American College of Obstetricians and Gynecologists has published recommendations regarding prioritization of gynecologic visits, including a section on how should provision of contraception be optimized? Highlights include:
- Telehealth can be used to screen new clients requesting contraceptives that can be self-administered; clients may be safely screened and offered prescriptions if they do not have contraindications. Manage adverse effects related to contraceptives by telehealth, when possible.
- Prescription Refills: Refills for existing prescriptions can be made through telehealth. Prescribe enough refills to minimize trips to the pharmacy—ideally for a full year. Encourage clients to fill prescription contraceptives by mail or at drive-through pharmacies, when available.
- Emergency Contraception: Counsel clients on the use of EC, including both over-the-counter and prescription options. Provide advance prescriptions for EC, particularly for ulipristal acetate.
- Continue to offer insertion and removal of long-acting reversible contraception (LARC). If provision of LARC methods or permanent contraception is unavailable during this pandemic, offer contraceptives that can be self-administered until placement is possible.
Clinics are advised to develop a written policy that prioritizes which client visits will be done in person or remotely. It is critical to revise the policy frequently based on current local or state physical distancing laws, the availability of clinician and non-clinician staff (especially if absences are prevalent due to infection, self-isolation, caring for family members, etc.), available supplies of personal protective equipment (PPE), etc. See the FPNTC’s Prioritization of In-Person and Virtual Visits During COVID-19: A Decision Making Guide for Staff for more information.
What does it look like to provide curbside pickup?
OPA has endorsed the option of curbside pickup for providing methods or medication supplies during the public health emergency. Appropriate PPE should be used (e.g. gloves that are changed between each interaction, and use of a face mask). Use procedures to use physical distancing strategies; for instance, one option is to put the medication on a table, walk away, and allow the client to get out of the car, pick it up and drive away. Another is to walk the medication or test kit to a car, place the package on the hood of the car, and have the client retrieve it. Medications should be clearly labeled and documented in the medical record just as if it were given in-person. There must also be a way to verify the client’s identity; some clinics do this by having the client text their auto license plate number to insure that the delivery is made to the correct person.
How can family planning providers deliver medication by mailing it to clients at home?
OPA supports the option of mailing prescriptions or supplies to clients at home during the public health emergency, if the client has no concern with confidentiality and consents to having supplies mailed to their address. Medications should be clearly labeled and documented in the medical record just as if they were provided in-person. Family planning providers should consult their state’s pharmacy regulations.
For insured clients, family planning providers can encourage them to ask their pharmacies to deliver medications; in some communities, pharmacies are offering free or low-cost delivery during the public health emergency. Some insurance companies are also offering mail-order options for clients.
How can we effectively utilize nurses and medical assistants when they are working from home?
It is likely that nurses and medical assistants can continue to provide many of the same services that they provided at the clinic, while at home. For example, providing client-centered counseling and education that they have been trained to conduct, using telehealth. Many video conferencing services provide the option of a virtual waiting room, as do some electronic health record telehealth systems. They can also call or contact clients to let them know that services are still available, send reminders, promote available, no-contact services via social media, conduct outreach, conduct quality assurance activities, participate in training, etc. Staff should continue to use client-centered practices in accordance with QFP recommendations while providing services virtually, including using a professional, distraction-free environment, maintaining client confidentiality, and fostering a relationship built on trust, rapport, and shared decision making.
Last Updated May 21, 2020
Note: This toolkit contains links to outside sources which may refer to services outside the scope of Title X (including care for pregnant individuals). The views expressed do not necessarily reflect the views of FPNTC or HHS/OASH/OPA, nor should inclusion be construed as an endorsement by FPNTC or HHS/OASH/OPA.