Impact, Scale and Sustainability

Upstream USA is a nonprofit working to reduce unintended pregnancy and improve best-in-class contraceptive care for patients across the nation. In 2014, Upstream trained one health center serving a few thousand women a year. Just over five years later, Upstream is on a trajectory to reach health centers that will serve more than 1 million patients annually. Across the United States, our health center partners have been able to center patient choice and achieve lasting improvements in contraceptive care and access, long after our work together has concluded.

25% reduction in births from unintended pregnancies in Delaware

Following the launch of Upstream’s statewide initiative in Delaware in 2014, this data is based on a report by the Centers for Diseases Control, using data from the Pregnancy Risk Assessment Monitoring System (PRAMS) survey. Births are categorized as wanted then or sooner, wanted later, not wanted, or mother unsure. Percent unintended shown here includes births reported as wanted later or not wanted, as a percent of all births.

“Prevalence of Selected Maternal and Child Health Indicators* for Delaware, Pregnancy Risk Assessment Monitoring System (PRAMS), 2012-2015” and “Prevalence of Selected Maternal and Child Health Indicators for Delaware, Pregnancy Risk Assessment Monitoring System (PRAMS), 2016-2017

Patients surveyed feel empowered to make their own decisions about which birth control method is right for them

Upstream conducts patient surveys at Upstream-trained health centers to assess whether patients feel they were in charge of choosing their own method, that they feel listened to by their providers and that they feel no pressure to choose any method of birth control.


of Delaware patients did not feel pressured to choose a specific method of birth control.


of Delaware patients made their own choices about birth control.


of Delaware patients feel that health center staff listen to them and their preferences. 

Survey of 554 patients at Upstream-trained Delaware health centers conducted July–September 2017. Patients who discussed birth control were asked (1) and (3); patients who started a contraceptive method were asked (2). Learn more about our commitment to patient choice.

Estimated unintended pregnancy rates dropped 24% among Delaware Title X patients, compared to 3% nationally

Child Trends issued a report using available contraceptive data from 2014 to 2017 in Delaware among Delaware Title X family planning clients aged 20–39. The observed movement from moderately effective contraception to highly effective Long-Acting Reversible Contraception (LARCs), paired with a small decrease in no method, was linked to a substantial simulated decrease (24.2 percent) in the unintended pregnancy rate among this population. The complete report, including methodology and limitations, was commissioned by Upstream and can be found at Child Trends.

FamilyScape simulations using state-level Title X data from Delaware and from the U.S. Title X data, 2014-2017

Moderately effective method usage increased about 7 percentage points in Delaware between 2017 and 2018

Percentage of contraceptive use* among Delaware women 18-49 years, 2017-2018. *Did you or your partner do anything the last time you had sex to keep you from getting pregnant? (Yes/No) …If “YES” then…what did you or your partner do the last time you had sex to keep you from getting pregnant? 

Delaware Department of Health and Social Services, Division of Public Health, DE BRFSS 2017-2018 data.

Statistically significant, causal impact in Delaware

The American Journal of Public Health published a peer-reviewed article showing that Upstream had statistically significant, causal impact in Delaware.

Learn More

Upstream intervention sustained 3+ years post-intervention

Cumulative number of IUDs and implants provided at The Door

The chart shows the cumulative number of IUDs and implants provided at a health center in New York City. Three-and-a-half years after completing our work, the practice change as a result of our intervention has been sustained, and patients continue to access the full range of contraceptive methods, including IUDs and the implant.

Self-reported data provided by the health center

Providers increasingly document patients’ reproductive health goals as part of routine screening

PISQ adoption chart

This chart shows the percentage of unduplicated patients aged 15-44 with a Pregnancy Intention Screening Question (PISQ) response documented in a dedicated EHR field over a 12-month period prior to and following Upstream engagement. Because reporting varied slightly by agency, results are not comparable across agencies.

Data were extracted from agency EHRs and analyzed by a third party

Transformative conversations

Prior to our work together, Dr. Janice Tildon-Burton’s staff were not regularly asking patients a Pregnancy Intention Screening Question. Dr. Tildon-Burton tells a moving story about the transformative power of having the conversation: [It] just sums up the reason why I’m here and why I do what I do.”

Our commitment to measurement, evaluation and learning

Upstream believes that regular monitoring and evaluation is central to achieving lasting change. We review a number of indicators with our health center partners to affirm access and choice. In addition to the results presented here, we regularly review data such as which birth control methods patients are choosing, if the patient chose the method voluntarily, if the patient felt pressured, and whether the patient was asked a pregnancy intention screening question. There is no “right” level of contraceptive use or “best” method choice.