Policy impacts on contraceptive access in the United States: a scoping review

Contraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.


Introduction
Reproductive health politics influence if, when, and how people access health services, factor into reproductive decision-making, and ultimately influence the health and wellbeing of individuals, families, and communities. Throughout history, policy decisions have impacted contraceptive access, in particular. For example, the distribution of contraception was criminalised in 1873 through the Comstock Act (Solinger, 2013), and in Buck v. Bell in 1927, the Supreme Court upheld the legality of forced sterilisation (Price, 2010;Solinger, 2013). Federal and state legislation has also funded abstinence-only sex education, which limits contraceptive access by restricting information about birth control and safe sex (Santelli et al., 2017;Solinger, 2013).
Contraceptive care is made more available and affordable through policies, such as Title X of the Public Health Service Act of 1970 (Title X), which funds community-based health facilities (Dawson, 2020;Solinger, 2013), and the 1972 Medicaid expansion, which funds family planning services and supplies (Ranji et al., 2016). More recently, the Affordable Care Act (ACA) and subsequent amendments established a new healthcare marketplace, requirements for contraceptive care coverage, and expanded dependent and Medicaid coverage (Redhead & Kinzer, 2015;Sonfield, 2011). Many of these provisions remain in place, although the Supreme Court has limited the ACA's authority by upholding religious and moral exemptions (Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania, 2020) and making Medicaid expansion optional for states (National Federation of Independent Business v. Sebelius, 2012).

Healthcare access framework
By applying Levesque et al.'s (2013) healthcare access framework, the individual and system-level factors that determine contraceptive access can be concretely examined across five dimensions that interact to generate healthcare access: (1) approachability, (2) acceptability, (3) availability and accommodation, (4) affordability, and (5) appropriateness. The first dimension, approachability, refers to community members' ability to perceive the need for care, which can be supported through targeted education and outreach materials. Acceptability refers to the ability to seek care, which can be dependent on social norms that allow for services rather than creating stigma, embarrassment, fear of judgment, shame, and lack of trust in health care. Availability and accommodation refer to the ability to physically reach care in a timely manner, which is influenced by how far community members live from services, clinic hours of operation, and the ability to access transportation. These issues can produce barriers to care for low-income people and those living in rural areas in particular . Affordability refers to the ability to pay for care, which is related to patient income, the cost of services, federal and local clinic funding, and patient access to health insurance. The cost of family planning services and a lack of health insurance are some of the most common barriers that patients cite as reasons they are unable to pay for reproductive healthcare (Zimmerman, 2017). Finally, appropriateness refers to patients' ability to engage with care, meaning that services must match patient needs and priorities, and health providers must be adequately trained to provide appropriate and unbiased care (Swan, et al., 2020;Beeson et al., 2014;Gomez et al., 2014;Levesque et al., 2013).

Current study
Applying Levesque et al.'s (2013) healthcare access framework to explore the role of US policy in determining contraceptive access, the following research question guided this study: How has federal US policy passed from 2009 to 2019 impacted contraceptive access? To answer this question, empirical research that has examined the impact of recent US federal policy on contraceptive access was identified and summarised. Due to the breadth of the research topic and the focus on describing existing research rather than assessing the quality of the studies, a scoping review methodology was used (Arksey & O'Malley, 2005).

Methods
Using Arksey and O'Malley's (2005) methodological framework for conducting a scoping study, the study's research question was identified and then selected relevant studies were located. Five searches in PubMed were conducted, one for each category of the guiding healthcare access framework (Levesque et al., 2013). Specific policies previously identified in a systematic grey literature search were considered (see Swan, 2021) and also keywords related to that category of access (e.g., transparency, norms, cost, bias). The exact search terms for each of these searches are available in Appendix 1. This PubMed search was conducted from July 27th to 29th, 2020, retrieving 1562 results, which were supplemented with 21 additional sources identified during the same time frame through a Google Scholar search of each policy and contraceptive access keyword (i.e., "family planning" OR contraceptive OR "birth control").
After removing duplicates (n = 145) and screening titles and abstracts for relevance and US setting (n = 1275 excluded), a full-text review of the remaining sources (n = 163), excluding those that did not examine policy (n = 41), only included policy changes prior to 2009 (n = 10), were non-empirical (n = 9), only included state-level policy (n = 3), or were not related to contraceptive access (n = 4) was conducted. This left 96 empirical studies (see Fig. 1). Next, the data was charted, recording information about each study that met the inclusion criteria (Arksey & O'Malley, 2005). Finally, the study findings were collated and summarised (Arksey & O'Malley, 2005), organising the literature thematically using Levesque et al.'s (2013) dimensions of healthcare access and according to the policy that each study investigated. The purpose of this scoping review was to provide a broad overview of empirical findings relevant to the influence of policy on contraceptive access. In line with this study's purpose as well as Munn et al.'s (2018) and Arksey and O'Malley's (2005) guidelines on scoping review procedures, an assessment of the methodological limitations of the identified empirical literature was outside of the scope of the current study. These screening and data extraction procedures were conducted by one reviewer, and the methodology and results were reviewed and approved by a panel of four subject and methodological experts.

Findings
A summary of the 96 empirical studies about the impact of recent US federal policy on contraceptive access, which were identified through a scoping review, is presented below, organised by policy. For a more in-depth description of the main findings of each study and a mapping of the healthcare access dimensions relevant to each study, see Appendix 2.

Abstinence education
Decades of policy changes have at times promoted abstinence-only sex education and at other times endorsed more comprehensive sex education. For example, after years of increasing funding for abstinence-only sex education, there was a steep decline beginning in 2009 (Fox et al., 2019). In another notable recent change, abstinence-only sex education programs were refunded and rebranded as Sexual Risk Avoidance Education through the Consolidated Appropriations Act of 2012 and the Bipartisan Budget Act of 2018 (Swan, 2021). This review identified two studies related to the impact of policies that fund abstinence-only sex education. These studies indicated that funding abstinence-only sex education programs is not associated with positive outcomes (Fox et al., 2019) and, in fact, can lead to negative outcomes such as increased birth rates among adolescents (Fox et al., 2019;Santelli et al., 2017).

Family planning medicaid waivers
This review identified one study that investigated the impact of a Sect. 1115 Medicaid waiver to expand family planning Medicaid eligibility. From before to after waiver implementation in 2011, this study showed increased use of more highly effective contraceptive methods, including long-acting reversible contraception (LARC), and increased preventive screening utilisation among Medicaid and Title X patients (Dunlop et al., 2016).

Military contraceptive policy changes
A study investigating how military contraceptive policy impacts contraceptive use found that a 2015 Navy policy change expanding contraceptive access during basic training (by increasing education about contraception and providing walk-in contraceptive clinics) increased overall contraceptive use and LARC use specifically. In contrast, a 2016 Marine Corps policy change restricting contraceptive access (by emphasising contraceptive injections for menstrual suppression and reducing the availability of LARC) during basic training decreased contraceptive use and LARC use and increased childbirth rates (Roberts et al., 2020).

Guidelines for quality care
In 2010, the US Centers for Disease Control and Prevention published federal guidelines for contraceptive use entitled the US Medical Eligibility Criteria for Contraceptive Use (updated in 2016; Curtis et al., 2016a). They also published the US Selected Practice Recommendations (published in 2013 andupdated in 2016;Curtis et al., 2016b) and the Providing Quality Family Planning Services recommendations (published 2014, updated 2016. These documents provide government recommendations for family planning providers, and many healthcare governing agencies and leadership organisations have subsequently endorsed and adopted them. This review identified three studies that investigated the impact of these guidelines, concluding that they have had positive impacts. Title X family planning providers reported that the 2014 Quality Family Planning Services recommendations strengthened client-provider relationships, empowered clients, improved reproductive healthcare access, and linked providers to evidence-based practices (M. Simmons et al., 2016). The Medical Eligibility Criteria for Contraceptive Use guidelines appeared to help align providers' knowledge and beliefs about contraception with best practices, decreasing false perceptions about intrauterine device (IUD) safety issues (K. B. Simmons et al., 2018;Zapata et al., 2019).

Teen Pregnancy Prevention Program
The Teen Pregnancy Prevention Program was established in 2009 through the Consolidated Appropriations Act of 2010 to provide competitive grant funding for teen pregnancy reduction (Fernandes-Alcantara, 2018). Studies examining the impact of such programs (n = 3) found that, among young residential group home residents, such programs increased reproductive health knowledge, improved attitudes about contraceptive use and healthy sexual behaviors, increased self-efficacy regarding relationships and contraceptive use, and increased intentions to use contraception (Green et al., 2017;Manaseri et al., 2019;Oman et al., 2016).

Title IX of the Education Amendments
Changes in 2011 to Title IX of the Education Amendments (Title IX) required colleges to make efforts to prevent campus sexual violence (Larkin, 2016). A few studies that investigated the impact of these recent Title IX updates (n = 4) indicated that these changes have shed light on and sought to fill gaps in university policies regarding sexual assault and sexual harassment (Bellis et al., 2018;Miller, 2018). These changes are thought to have increased student empowerment to report victimisation experiences (Miller, 2018), potentially increasing access to supportive services, including contraceptive care, following victimisation. However, students have reported barriers to reporting victimisation such as confidentiality concerns (Holland & Cortina, 2017a), and faculty and staff have reported negative unintended consequences such as decreased trust (Holland & Cortina, 2017b;Miller, 2018). Title IX relates to contraceptive access in that supportive services following sexual victimisation often include contraceptive care (Bates, 2022); however, these reviewed studies provide inconclusive evidence as to the impact of the recent Title IX changes on contraceptive access as studies have found conflicting findings regarding how the updated policy may impact help-seeking behaviors after victimisation.

Title X of the Public Health Service Act
Many studies examined the impact of the Title X Family Planning Program (originally established in 1970 and amended in 2016 and 2018) on contraceptive access (n = 25), finding that clinics that received Title X funding were more likely than facilities without Title X funding to provide more comprehensive contraceptive care (Carter et al., 2016;Robbins et al., 2017;Wood et al., 2014) and to provide onsite contraceptive methods (Carter et al., 2016;Centers for Disease Control & Prevention, 2011;de Bocanegra et al., 2014;Jatlaoui et al., 2017;Satterwhite et al., 2019;Wood et al., 2014), including LARCs Bornstein et al., 2018;Carter et al., 2016;de Bocanegra et al., 2014;Jatlaoui et al., 2017;Park et al., 2012;Wood et al., 2014). Despite these instances of improved contraceptive access at Title X facilities, one study indicated that Title X clinics did not differ from other facilities in the accessibility of emergency contraception (French et al., 2018).
Title X facilities were more likely than non-Title X facilities to meet the needs of specific at-risk populations by providing youth-friendly services such as protecting confidentiality and providing youth with contraception (Beeson et al., 2016;Carter et al., 2016;Crain et al., 2020;Kavanaugh et al., 2013;Mead et al., 2015), providing materials and services in Spanish, offering extended clinic hours, and providing outreach to hard-to-reach populations . Additionally, Title X providers were less likely than other providers to hold misconceptions about the safety of contraception (Jatlaoui et al., 2017;Shah et al., 2019;K. B. Simmons et al., 2018;Tyler et al., 2012). Although Title X patients were less likely than women nationally to use more effective methods such as LARCs (Fowler et al., 2019), Title X patients were more likely to receive communication about contraception (Liddon et al., 2018), and the presence of a Title X clinic was associated with a decrease in female high school dropout rates (Hicks-Courant & Schwartz, 2016). Studies also indicated that patients reported positive perceptions of Title X clinics, and many patients preferred to receive care at these facilities rather than non-Title X facilities (Frost et al., 2012;Oglesby, 2014).
Some studies suggested barriers to Title X care, indicating that non-Title X facilities were more likely than Title X clinics to have providers trained in IUD insertion (Tyler et al., 2012) and to provide levonorgestrel IUDs, specifically (Centers for Disease Control & Prevention, 2011;Jatlaoui et al., 2017). One study investigated the potential impact of a ban implemented in 2019 which prohibits Title X providers from offering abortion referrals and abortion counselling (formally known as the Protect Life Rule and known by pro-choice advocates as the "domestic gag rule"; Belluck, 2019). This study explored the impact of a similar 2013 policy in Texas, finding that 79% of surveyed family planning organisations had lost their Title X funding by 2015 and reporting a decrease in teen clients attributed by administrators to the loss of confidential services previously guaranteed under Title X (Coleman-Minahan et al., 2019). This study's findings speak to the potential impact of the federal Title X Protect Life/domestic gag rule.

Violence Against Women Act
Originally established in 1994, the Violence Against Women Act increased penalties for sexual assault perpetration and prohibited survivors from being billed for forensic exams (Tennessee et al., 2017). The Violence Against Women Act was reauthorised in 2013, including incorporation of the Campus Sexual Violence Elimination Act into the Violence Against Women Act. This increased requirements for sexual assault responses at academic institutions. One study exploring how gaps in the Violence Against Women Act, including the 2013 reauthorisation, impacted costs of services for sexual assault survivors found that hospitals billed privately insured survivors for an average of $948 of services not paid under their insurance policy (Tennessee et al., 2017). These costs included prescription medication such as emergency contraception. This study indicates that gaps in the Violence Against Women Act may create affordability barriers to healthcare, including emergency contraception, following sexual assault.

Veterans Access, Choice, and Accountability Act
The Veterans Access, Choice, and Accountability Act of 2014 expanded healthcare options for veterans with specific burdens by allowing them to receive healthcare with choice contracted providers (Gawron et al., 2018). Studies exploring the impact of this Act showed that it increased provider education and patient healthcare access, including reproductive healthcare access, especially in rural areas (Albanese, 2018;Hussey et al., 2016;Mattocks et al., 2017;Stroupe et al., 2019). However, gaps in access remained, including preventive and gynaecological services and in providing respectful care to female veterans (Albanese, 2018;Hussey et al., 2016;Mattocks et al., 2017).

Discussion
Most of the empirical studies identified in this scoping review examined the role of the ACA (n = 53) and Title X (n = 25), showing many benefits of both policies for contraceptive access. Other studies identified in this review reported on the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across all five 5 Page 10 of 72 of Levesque et al.'s (2013) healthcare access dimensions. Figure 2 presents a visual depiction of how the studies in this scoping review relate to the healthcare dimensions, with the majority of studies relating to the affordability dimension (58%).
Specifically, the ACA improved contraceptive access across all five healthcare access dimensions, although most studies described its positive impact on contraceptive affordability, through the contraceptive mandate, increased dependent coverage, and Medicaid expansion. Whereas studies showed improved contraceptive access related to changes to Title X across the healthcare access dimensions, most of these improvements were related to the availability and appropriateness of contraceptive care. Policies impacting veterans and active-duty servicepeople, overall, led to improved contraceptive access, particularly relevant to the availability and appropriateness healthcare access dimensions. New guidelines promoting quality contraceptive care improved the appropriateness of contraceptive care. The Teen Pregnancy Prevention Program improved contraceptive care by impacting the approachability, acceptability, and availability dimensions of healthcare. Changes to Title IX impacted contraceptive access in positive and negative ways, largely by impacting the acceptability dimension.
Despite the many federal policy decisions that have improved contraceptive access in the past decade, this review of empirical literature also showed some decreases in contraceptive access following policy changes. For example, funding for abstinence-only sex education has negatively impacted the approachability and acceptability of contraception. Additionally, while studies showed many benefits of the ACA for contraceptive access, several studies reported decreased approachability and acceptability related to lack of awareness about coverage and confidentiality concerns related to young adult coverage under the ACA's dependent coverage. Studies also indicated that contraceptive care restrictions for active-duty Marines have limited contraceptive access, and attempts to increase contraceptive access for veterans have left gaps related to the availability and appropriateness of contraceptive care. These issues are identified as opportunities for continued research and for policy and practice intervention.
Although the current study was limited to examining contraceptive access, policy changes related to other aspects of family planning care have also altered access to family planning services. Since true healthcare access means that comprehensive family planning services (ranging from contraceptive and abortion care to fertility and pregnancy services) must be available (J. Johnston & Zacharias, 2017), it is difficult to compartmentalise aspects of family planning care. Exploring the comprehensiveness of family planning care rather than studying services in silos changes study methods and findings. One avenue for future research is the impact of recent policies on abortion access and on the overall comprehensiveness of family planning care. Additionally, future research could build on this study of US federal policy by investigating the role of state-level policies on contraceptive access and on overall family planning access.
There is also a need for more research on policies other than the ACA and Title X, which were by far the most researched policies regarding contraceptive access. Future research is needed to investigate, for example, the impact of Title IX on contraceptive access. The current analysis indicated possible unintended effects of Title IX, including potential confidentiality concerns that limit disclosures and service utilisation and negative impacts on university culture. Continued research could increase understanding of these issues, identify areas for intervention or policy change, and consider how these policy changes have explicitly impacted healthcare utilisation and contraceptive care following victimisation. Such research could include a cost-benefit analysis to help understand the positive and negative impacts of these Title IX regulations on university students as well as faculty and staff.

Policy impacts on marginalised populations
This study also highlights ways that policy has impacted contraceptive access and family planning outcomes for some vulnerable groups. The sources reviewed indicated that age sometimes acted as a barrier to contraceptive access for minors and for young adults included on health insurance as dependents. Policy changes over the past decade have alleviated some of these concerns through legislation that made emergency contraception available to minors over the counter. The ACA and optional state-level Medicaid expansion also helped reduce uninsurance among young adults, including those ageing out of the foster care system. However, the research reviewed in this study also indicated increased barriers to care for young Americans following the ACA, which worsened confidentiality concerns for this group. People living in rural areas have also historically faced barriers to care, although the ACA seems to have reduced regional differences in contraceptive costs and use. Additionally, the Veterans Access, Choice, and Accountability Act has increased healthcare access in rural areas, although it has left gaps related to specific women's healthcare needs.
A few sources in this review also considered the role of race and ethnicity on contraceptive access. These sources indicated that the ACA decreased racial disparities in contraceptive access and highlighted the importance of Title X in serving racial/ethnic minority patients as well as low-income patients. In light of the recent changes in the Title X program, which have forced many clinics to leave the program in order to continue providing comprehensive care, continued research is needed on the ways that this change may disproportionately impact minority groups and low-income populations. Additionally, the empirical literature reviewed in this study made little to no mention of other populations (e.g., sexual/gender minorities, people with disabilities, people with health conditions such as obesity) who are likely to face disproportionate barriers to contraceptive care based on social, demographic, and health factors. The sources reviewed in this study provide important insights into the impacts of recent policy changes on contraceptive access for certain vulnerable populations, but there is a need for continued research on policy impacts for these and other marginalised groups.

Suggestions for improved policy
This study identified policy needs that could be addressed to improve contraceptive access. Improving contraceptive access begins with increasing the availability of contraceptive information and reducing stigmatising rhetoric by eliminating abstinence-only sex education policies and programs and instead promoting comprehensive sex education (Santelli et al., 2017). Investing in local contraceptive care and providing care options for low-income Americans, through funding streams such as the Community Health Center Fund, would also increase the availability and affordability of care. Such provisions are even more important considering the decreased community clinic options as a result of the Protect Life/domestic gag rule, which led to many clinics withdrawing from the Title X program in order to continue providing comprehensive care. Although the Protect Life/domestic gag rule was revoked in 2021, its impact on contraceptive access over the two years it was in effect is not fully known. Concerns with decreased confidentiality following the ACA could be addressed through policy changes to ensure confidentiality, perhaps using the confidentiality measures included in Title X as an example. Finally, policies aiming to reduce or eliminate healthcare costs following sexual assault could reduce barriers to care and increase access to contraception for survivors.

Practice gaps
This study also identified practice gaps that could be addressed to improve contraceptive access across Levesque et al.'s (2013) dimensions of healthcare access. First, filling gaps at Title X clinics could include increasing the onsite availability of contraceptive methods and provider training in all contraceptive methods and ensuring that when comprehensive contraceptive care cannot be provided onsite, referrals are provided to ensure patient autonomy and continuity of care. Second, there is a need for increased compliance with contraceptive recommendations among family planning providers, indicating an opportunity for increased provider education and adoption of established guidelines. Third, increased outreach efforts could improve contraceptive access by addressing confusion about ACA benefits and helping community members understand their coverage. Finally, increasing the consistency and transparency of contraceptive policies within varying branches of the military and filling gaps left by the Veterans Access, Choice, and Accountability Act, particularly in rural areas, could promote reproductive autonomy and the comprehensiveness of contraceptive care.

Limitations
One limitation of the current study is that it is possible and even likely, that these methods did not identify all relevant federal policies that have recently influenced contraceptive access. By design, the scoping review only captured those studies that included the prescribed keywords. Since policy analysis can vary greatly in methodology and sometimes relevant research does not name pertinent policy changes, some studies were likely excluded from the current review. For example, although many studies have examined various programs funded by the Teen Pregnancy Prevention Program, this scoping review only identified three such studies. Intervention studies that did not explicitly identify the policy origins of their programs' funding may not have been captured by the current analysis. Future research could more explicitly investigate the role of such interventions, funded through the policies and programs discussed in this review, on contraceptive access and subsequent family planning outcomes. Another limitation is that these screening and data extraction procedures were conducted by one reviewer. This lack of independent screening from multiple reviewers increases the risk of bias. However, a panel of subject and methodological experts provided feedback on and approved the methodology prior to study initiation and reviewed and suggested edits to the study results prior to study completion, increasing the trustworthiness of the findings.

Conclusion
This scoping review has summarised findings regarding the impact of US federal policies passed from 2009 to 2019 on contraceptive access. Two policies in particular, the ACA and Title X, were commonly investigated in the reviewed empirical studies, with findings showing many benefits of both policies for contraceptive access. Studies examining the impact of these policies and several others revealed recent strides in improving contraceptive access across the five dimensions of healthcare access. These studies also identified policy and practice gaps and opportunities for continued research, practice, and policy action that can increase understanding of this topic and improve contraceptive access. In particular, attention to policy impacts for marginalised populations is needed in future research.

Appendix 1
Search terms used to identify sources for scoping review.

Search
Terms used Search 1: Approachability ("family planning" OR contracept* OR "birth control" OR "reproductive") AND (knowledge OR health literacy OR information OR awareness) AND (HIPAA OR HITECH OR abstinence education OR "Personal Responsibility Education Program" OR "sexual risk avoidance education" OR "adolescent family life act") Search 2: Acceptability ("family planning" OR contracept* OR "birth control" OR "health utilization" OR health OR acceptability OR stigma OR trust OR seek* OR norm OR value OR culture) AND ("Title IX" OR "Campus SaVE Act" OR "Campus Sexual Violence Elimination Act" OR "Violence Against Women Act") Search 3: Availability and Accommodation ("family planning" OR contracept* OR "birth control" OR availability OR reach OR transportation OR location OR hour OR appointment) AND ("Community health center fund" OR "Title X" OR "Protect Life Rule" OR "domestic gag rule" OR defund* Planned Parenthood OR Veterans Access, Choice, and Accountability Act) Search 4: Affordability ("family planning" OR contracept* OR "birth control" OR "health utilization") AND ("Affordable Care Act" OR "Women's Health Amendment" OR "Medicaid expansion" OR "contraceptive mandate" OR "National Defense Authorization Act of 2011" OR "Tricare Young Adult" OR "Association Health Plans" OR "short-term health plan") Search 5: Appropriateness ("family planning" OR contracept* OR "birth control" OR appropriate OR satisfaction OR bias OR engage OR quality OR adequacy) AND ("Teen Pregnancy Prevention Program" OR "Medical Eligibility Criteria for Contraceptive Use" OR "Healthy People 2020" OR "Selected Practice Recommendations" OR "Providing Quality Family Planning Services" OR "domestic gag rule" OR "Title X" OR "VA Mission Act of 2018" OR "Comprehensive Contraceptive Counseling and Access to the Full Range of Methods of Contraception")

Appendix 2
Empirical literature sources identified for scoping review (N = 96). Many women veterans reported using the program for gender-specific services not available at VA health centers AR = Approachability, AC = Acceptability, AV = Availability/Accommodation, AF = Affordability, AP = Appropriateness.