Reenvisioning Title X to Meet Early Pregnancy Needs

Without access to timely pregnancy confirmation by ultrasound, some patients decide to seek advice in online communities5 ; in crisis pregnancy centers (CPCs), which are facilities that pose as health care institutions and aim to dissuade clients from seeking abortions; or in emergency departments (EDs), which are often an inefficient use of resources and may not meet patient needs in early pregnancy.6 CPC and ED utilization for routine pregnancy confirmation reflects a gap in the health care system-one that we believe can be filled through federally funded reproductive health clinics. Title X services include contraceptive counseling and management, fertility services, screening and treatment of sexually transmitted infections, and reproductive preventive health interventions such as the human papillomavirus vaccination.7 In its most recent Title X five-year program plan, OPA has prioritized health equity, expanded service access, and emphasized high-quality service delivery.8 The program explicitly does not fund abortions, but supports nondirective pregnancy options counseling and referrals to prenatal or abortion care.7 "Pregnancy testing and counseling" is explicitly included within the scope of Title X.7 Although point-of-care urine pregnancy testing is offered in Title X programs, this is insufficient to confirm the pregnancy location, gestational age, or presence of multiple gestations. Black and Indigenous pregnant individuals are two to three times more likely than their White counterparts to have a pregnancy-related death, reflecting deep-seated structural racism in the United States and in health care.11 Additionally, pregnant individuals with lower incomes, those from rural communities, and adolescents suffer from diminished access to reproductive health services.12–14 Thus, any efforts to improve health care in pregnancy must be guided by a lens of equity. EXPANDING THE EARLY PREGNANCY ASSESSMENT CLINIC Early pregnancy assessment clinics (EPACs) are an integrated model for outpatient management of the 25% of patients who experience early pregnancy complications such as vaginal bleeding or pain.4 This model is well-established in Canada and the United Kingdom, and has been growing in the United States.20 Most EPACs confirm pregnancy location and viability in patients with firsttrimester vaginal bleeding or pelvic pain, with comparable safety and improved cost and efficiency compared with the ED setting.21,22 EPACs ideally integrate miscarriage,