Survey of Health Care Providers

Form Approved
OMB Number: 0920-XXXX
Expiration Date: XX/XX/XXXX

2012–2013 SURVEY of HEALTH CARE PROVIDERS
This survey is being sent to a selected sample of health centers and providers. Please do not distribute to others for completion.

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information
unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-xxxx).

I.	

Provider, Patient and Practice/ Health Center Characteristics

Please answer each of the following questions as they relate to you, your patients, and the practice/health center at which you
received this survey.
1.

2.

3.

4.

5.

Which of the following describes the setting of this practice/
health center? (select all that apply)
Community health center
Family planning clinic
Health department (state or local)
HMO or Hospital
Indian Health Service
Planned Parenthood affiliate
Private practice
School based health clinic
Sexually transmitted infection clinic
University clinic
Other (please specify)____________________________

6.

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Does this practice/health center receive any non-fee-for-service
income to support family planning services? (select all that apply)
None
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Private grant(s)
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State appropriations
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Section 308 of Public Health Service Act
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Title V (MCH Block Grant)
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Title X (Family Planning)
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Don’t know
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Other ________________________________________
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In what state is your practice/health center located?
____________________________________________________
In this practice/health center, how many health care providers,
including you, provide family planning services*?
____________________________________________________

Certified nurse midwife
Nurse practitioner
Nurse
Physician
Physician assistant
Other (please specify) ____________________________
7.

Female

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Family medicine
Obstetrics/gynecology or family planning/reproductive
health

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Primary (general health) care
Other (please specify) ____________________________
8.

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What is your primary clinical focus at this practice/health
center? (select one)
Adolescent health or pediatrics

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How many years has it been since you completed your most
recent formal clinical training (e.g., medical/nursing school,
residency/practicum/ clinical)?
Less than 5 years

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5-14 years
15-24 years
25 or more years
9.

On average, how many female patients of reproductive age do
you see per week? ___________________________________

10.

To approximately what percentage of your female patients of
reproductive age do you provide family planning services*?
0%
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1–24%
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25–49%
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50–74%
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75% or more
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What is your gender?
Male

What is your role as a health care provider? (select one)

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* For the purpose of this survey, a family planning service is any service related to postponing or preventing pregnancy. Family planning services may include a medical
examination related to provision of a method, contraceptive counseling, method prescription or supply visits. A patient may receive a family planning service even if the
primary purpose of her visit is not for contraception.
11.

Have you ever been formally trained in the insertion of the following contraceptive methods for women during the following time periods?
Trained to insert
during routine care

Copper intrauterine device (Cu-IUD or ParaGard®)
Levonorgestrel-releasing intrauterine device (LNG-IUD or Mirena®)
Contraceptive implant (Implanon®/Nexplanon®)

Trained to insert
Trained to insert
immediately postpartum immediately post-abortion

Yes

No

Yes

No

Yes

No

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N/A

N/A

N/A

N/A

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12.

Approximately what percentages of your female patients of reproductive age have the following characteristics? If unsure, give your best
estimate.
0-24%

25-49%

≥50%

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Pay for their visit using Medicaid or other state or federal assistance
Are racial or ethnic minorities
Have limited English proficiency
Are adolescents
Are 35 years of age or older

II.	

Health Care Provider Attitudes

Please answer each of the following questions as they relate to your attitudes when providing family planning services. Please do
not consult any source of guidance when answering the questions.
13.

How safe do you consider combined oral contraceptives (COCs) to be for the following groups?
Very safe

Safe

Unsafe

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Women with a history of bariatric surgery via restrictive procedures
(e.g., vertical banded gastroplasty)

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Women with a history of bariatric surgery via malabsorptive procedures
(e.g., Roux-en-Y gastric bypass)

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Women with rheumatoid arthritis

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Women with inflammatory bowel disease (i.e., Ulcerative colitis,
Crohn’s disease) without other risk factors for VTE

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Breastfeeding women ≥1 month postpartum without other risk factors for
venous thromboembolism (VTE)
Smokers 35 years of age or older
Obese women (BMI ≥30 kg/m2)

14.

Very unsafe Don’t know

How effective do you consider combined oral contraceptives (COCs) to be for the following groups compared to use by healthy women?
More effective

Equally
effective

Obese women (BMI>= 30 kg/m2)

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Women with a history of bariatric surgery via restrictive procedures (e.g., vertical
banded gastroplasty)

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Women with a history of bariatric surgery via malabsorptive procedures (e.g., Rouxen-Y gastric bypass)

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Women on anticonvulsant therapy
Women on antibiotic therapy
Women with inflammatory bowel disease (e.g., Ulcerative colitis, Crohn’s disease)
15.

Less effective Don’t know

How safe do you consider intrauterine devices (Cu-IUD or LNG-IUD) to be for the following groups?

Adolescents
Immediately postpartum women (less than 10 minutes after delivery of placenta)
Postpartum women (10 minutes after delivery of placenta to less than 4 weeks
postpartum)
Nulliparous women
Obese women (BMI ≥30 kg/m2)
Women with uterine fibroids
Women with HIV (not AIDS)

Page 2 of 7

Very safe

Safe

Unsafe

Very unsafe Don’t know

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16.

How safe do you consider DMPA (Depo-Provera®) to be for the following groups?
Very Safe

Safe

Unsafe

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Adolescents
Breastfeeding women <1 month postpartum
Breastfeeding women ≥1 month postpartum
Smokers 35 years of age or older
Obese women (BMI ≥30 kg/m2)
Women with a history of bariatric surgery via restrictive procedures
Women with rheumatoid arthritis not on immunosuppressive therapy
Women with inflammatory bowel disease
Women with complicated diabetes (i.e., nephropathy, retinopathy, neuropathy,
other vascular disease or diabetes of >20 years’ duration)
17.

For each of the following contraceptive methods, how safe do you think it is to start a woman on the day of her visit regardless of the
timing of her menses (‘Quick Start’) if you are reasonably certain she is not pregnant? Please answer for both adolescents and adults.
Adolescents

Adults

Safe

Unsafe

Don’t know

Safe

Unsafe

Don’t know

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Combined hormonal contraceptives (COCs, patch, ring)
DMPA
Contraceptive implant
Intrauterine devices (Cu-IUD or LNG-IUD)

III.	

Very unsafe Don’t know

Health Care Provider Practices

Please answer each of the following questions as they relate to your (or your clinical team’s) practices when providing family
planning services.
18.

In the past month, when counseling your typical female patient of reproductive age on family planning, how often have you (or your
clinical team) done the following?
Very often

Often

Not often

Never

Assessed the patient’s reproductive life plan (i.e., asked about their intentions regarding the
number and timing of pregnancies in the context of their personal values and life goals)

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Presented information regarding potential contraceptive methods with the most effective
methods presented first (tiered approach)

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Helped the patient think about potential barriers to using their selected method correctly
and develop a plan to deal with these barriers

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Used a method-specific informed consent form

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Informed adolescents that long-acting reversible contraceptives are safe and effective
options

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19.

In the past year, how often have you (or your clinical team) provided DMPA to adolescents?
Very often or often
Not often or never

Go to question #20.

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If “not often or never” please indicate why. (select all that apply)
a.

I rarely have adolescents as patients

b.

DMPA is unavailable in my practice/health center

c.

I am concerned about the safety of DMPA for adolescents

d.

I am concerned about side effects that may lead to discontinuation

e.

My adolescent patients generally prefer a different method

f.

My practice/health center protocol does not allow it

g.

Other reasons (please specify) _______________________________________

Page 3 of 7

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20.

In the past year, how often have you (or your clinical team) provided or prescribed COCs to breastfeeding women ≥ 1 month postpartum
without other risk factors for VTE?
Very often or often
Not often or never

21.

If “not often or never” please indicate why. (select all that apply)

Not often or never

I rarely have postpartum women as patients

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b.

I am concerned about the safety of COCs for breastfeeding women ≥ 1 month postpartum
without other risk factors for VTE

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c.

I am concerned about a decrease in breast milk production

d.

My postpartum patients generally prefer a different method

e.

My practice/health center protocol does not allow it

f.

Other reasons (please specify) ________________________________________________

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Go to question #22.

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If “not often or never” please indicate why. (select all that apply)
a.

I rarely have nulliparous women as patients

b.

IUDs are generally unavailable in my practice/health center

c.

I am concerned about the safety of IUDs for nulliparous women

d.

I am concerned about the effects on future fertility

e.

I am concerned about difficult insertion

f.

I am not trained in IUD insertion

g.

My nulliparous patients generally prefer a different method

h.

My practice/health center protocol does not allow it

i.

Cost barriers prevent me from providing IUDs to nulliparous women

j.

Other reasons (please specify)_______________________________________________

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When initiating the following contraceptive methods, please indicate if you or your practice/health center require the following exams and
tests for a healthy client. Please check all exams and tests that apply.
Blood pressure

Clinical breast exam

Bimanual exam and
cervical inspection

Cervical cytology
(Pap smear)

Chlamydia/ gonorrhea
screening

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COCs/patch/ring
Progestin-only pills (POPs)
DMPA
Contraceptive implant
Cu-IUD
LNG-IUD
23.

a.

In the past year, how often have you (or your clinical team) provided intrauterine devices (Cu-IUDs or LNG-IUD) to nulliparous women?
Very often or often

22.

Go to question #21.

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In the past year, when providing or prescribing combined hormonal contraceptives (COCs, patch, ring), how often did you start a woman
on the day of her visit regardless of the timing of her menses (‘Quick Start’) if you were reasonably certain she was not pregnant? Please
answer for both adolescents and adults.
(23a) Adolescents

Very often
or often
Not often
or never

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(23b) Adults
Very often
or often
Not often
or never

Go to question #23b
If “not often or never” please indicate why.
(select all that apply)

a.

I do not think it is safe

b.

I have liability concerns

c.

I do not have enough training

d.

I do not think it is appropriate for adolescents

e.

My practice/health center protocol does not allow it

f.

Other (please specify) _______________________

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Page 4 of 7

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Go to question #24
If “not often or never” please indicate why.
(select all that apply)

a.

I do not think it is safe

b.

I have liability concerns

c.

I do not have enough training

d.

I do not think it is appropriate for adults

e.

My practice/health center protocol does not allow it

f.

Other (please specify) _______________________

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24.

In the past year, when providing DMPA, how often did you start a woman on the day of her visit regardless of the timing of her menses
(‘Quick Start’) if you were reasonably certain she was not pregnant? Please answer for both adolescents and adults.
(24a) Adolescents

Very often
or often
Not often
or never

25.

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(24b) Adults

Go to question #24b
If “not often or never” please indicate why.
(select all that apply)

a.

I do not think it is safe

b.

I have liability concerns

c.

I do not have enough training

d.

I do not think it is appropriate for adolescents

e.

My practice/health center protocol does not allow it

f.

Other (please specify) ________________________

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If “not often or never” please indicate why.

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(select all that apply)

a.

I do not think it is safe

b.

I have liability concerns

c.

I do not have enough training

d.

I do not think it is appropriate for adults

e.

My practice/health center protocol does not allow it

f.

Other (please specify) ________________________

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4-6 weeks

3 months

6 months

12 months

Only if she has
problems or questions

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POPs
DMPA (routine follow-up other than for re-injection)
Implant
Intrauterine device (Cu-IUD or LNG-IUD)

In the past year, how often have you or your clinical team done the following?
Very often

Often

Not often

Never

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Provided an advance prescription for emergency contraception (EC) to a woman not
specifically seeking EC
Provided an advance supply of EC to a woman not specifically seeking EC
Provided or prescribed a contraceptive at the same time you provided EC
Provided a Cu-IUD as EC
27.

Go to question #25

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After initiating the following methods, please indicate when you advise healthy adult patients to come back for a follow-up visit.

COCs, patch, ring

26.

Very often
or often
Not often
or never

In the past year, how often did you or your clinical team dispense a year’s supply of pills (COCs or POPs) at one visit? Please answer for
both new and continuing users.
(27a) New Users

Very often
or often
Not often
or never
a.
b.
c.
d.
e.
f.
g.
h.

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(27b) Continuing Users
Very often
or often
Not often
or never

Go to question #27b
If “not often or never” please indicate why.
(select all that apply)

I do not think it is safe
My practice/health center does not dispense pills
My practice/health center protocol does not allow it
I have liability concerns
There is not enough supply in my practice/health
center
It is too expensive for my practice/health center
I am concerned about wasting pill packs if the
woman discontinues
Other (please specify) ________________________

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a.
b.
c.
d.

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e.

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f.

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g.

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h.

Page 5 of 7

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Go to question #28
If “not often or never” please indicate why.
(select all that apply)

I do not think it is safe
My practice/health center does not dispense pills
My practice/health center protocol does not allow it
I have liability concerns
There is not enough supply in my practice/health
center
It is too expensive for my practice/health center
I am concerned about wasting pill packs if the
woman discontinues
Other (please specify) ________________________

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28.

In general, how important to you are the following sources for staying informed about recommended clinical practices related to
contraception? Please answer for each source.

Conferences
Continuing education programs
Discussions with colleagues
Institutional practice protocols
Journals
Medication package inserts
Online resources
Professional organization publications or notifications
Textbooks (e.g., Contraceptive Technology)
U.S. Medical Eligibility Criteria for Contraceptive Use (MEC)
WHO MEC
WHO Selected Practice Recommendations for Contraceptive Use
Other (please specify) ___________________________________________

29.

Minor Source

Not Used

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For routine health care, at what age do you or your practice/health center recommend that
a woman begin routine cervical cancer screening? (select one)
Whenever she becomes sexually active

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Starting at age 18
Starting at age 21
Don’t know
Other (please specify) ___________________________

30.

Important Source

For routine health care, how often do you provide cervical cancer screening for a sexually
active, 25-year old patient with previously normal results?
Every visit

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Annually
Every 2 years
Every 3 years
Don’t know
Other (please specify) ___________________________

Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

Page 6 of 7

IV.	

Awareness of Guidelines

We want to know about your awareness of CDC’s contraceptive use guidelines.
31.

How did you learn about the following CDC contraceptive use guidelines? Please answer for both sets of
guidelines. (select all that apply)
2010 U.S. Medical
Eligibility Criteria for
Contraceptive Use
(U.S. MEC)

2013 U.S. Selected
Practice Recommendations
for Contraceptive Use
(U.S. SPR)

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I did not know about the guidelines before participation in this survey.
Professional organization publications or notifications
Conference attendance
Continuing medical education programs
Discussions with colleagues
Email alert from CDC
Institutional practice protocol
Journals
Online resources
Textbooks (e.g., Contraceptive Technology)
Other (please specify)
____________________________________________________________
32.

Have you used any of the following U.S. MEC materials?
U.S. MEC website
U.S. MEC color-coded summary chart in English
U.S. MEC color-coded summary chart in Spanish
U.S. MEC wheel
U.S. MEC iPhone/iPad application
U.S. MEC 2011 update with revised recommendations for postpartum contraceptive use
U.S. MEC 2012 update with revised recommendations for the use of hormonal contraception among women at high risk
for HIV infection or infected with HIV

33.

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What additional medical conditions or patient characteristics would you like to see recommendations for in the U.S. MEC?
(please specify) __________________________________________________________________________________________________
(please specify) __________________________________________________________________________________________________
(please specify) __________________________________________________________________________________________________

Page 7 of 7

Please share any additional comments that you may have in the space below.

Thank you for completing this survey!

Please return using the enclosed postage paid envelope.