Federal legislation enacted earlier this year gives the states flexibility to retool their Medicaid programs in ways that could be detrimental to women who have relied on Medicaid coverage to obtain family planning services. With the future of many state programs uncertain, Diana Greene Foster and colleagues' analysis of the impact of California's family planning program on fertility in the state, on page 126 of this issue of Perspectives on Sexual and Reproductive Health, is particularly timely.
Launched in 1997, Family PACT offers services to all California residents living within 200% of the federal poverty level who have no other coverage for reproductive health care; in 2002, it dispensed contraceptives to nearly a million women. In calculations based on the mix of methods that program participants used before and after enrollment, Foster and her coauthors estimate that Family PACT averted 205,000 pregnancies in 2002. These pregnancies would have resulted in 79,000 abortions and 94,000 births, including more than 21,000 births to teenagers. Analyses employing a variety of assumptions about contraceptive failure and method use show that the program makes its greatest impact by providing methods to women who would otherwise use none. The authors further estimate that averting 205,000 pregnancies a year would yield significant public-sector savings—more than a billion dollars over two years—on health and social services for women and their children. The data leave little doubt of the importance of programs like Family PACT to individual women, families and states.
Also In This Issue
•How people choose sexual partners is an important influence on their STD risk; understanding these choices thus is critical to the success of prevention interventions. In interviews with inner-city black youth, Katherine Andrinopoulos and colleagues find (see article) that young women desire monogamous romantic partners, rather than casual sex partners. Unfortunately, though, to fulfill a need for intimacy, they often settle for nonmonogamous partners. Males, meanwhile, seek multiple partners as a way to gain social status and to feel wanted, benefits that may help compensate for the lack of socioeconomic opportunities that is a recurring theme in their discussions. Both women and men judge potential partners' STD status on appearances. The authors make a convincing case that interventions for this group would do well to go beyond addressing adolescents' risk-related behavior to focus on their broader social contexts.
•Results of the first nationwide survey of publicly funded family planning clinics show that these facilities offer a wide range of contraceptive and related services, but suggest that financial constraints prevent many from complying with federal guidelines for STD screening or from adopting the most up-to-date technologies. According to Laura Duberstein Lindberg and colleagues (see article), some agencies appear to concentrate costly services in selected clinics, thus ensuring that services are available in their network while using resources efficiently. Other key findings are that the great majority of clinics counsel teenagers making a first visit on the importance of delaying sexual activity, and clinics use a variety of strategies to provide services to men and to accommodate non-English-speaking clients.
•The female condom is the only female-controlled method for preventing pregnancy and STDs, but it is little used and often ineffectively promoted. In a clinical trial described by Susan S. Witte and colleagues (see article), a relationship-based intervention aimed at increasing use of the method among women in long-term relationships proved more effective over the next three months than a more typical education intervention. Participation in the six-session intervention—which emphasized communication, negotiation and problem-solving skills, and gave participants opportunities to practice inserting and removing the device on a pelvic model—was associated with increased use of the female condom during follow-up and with increased intention to use the device at the end of the three-month period. In the absence of safe, effective microbicides, the authors consider the female condom a critical method for STD prevention and urge the development of innovative strategies to promote its use.
•As legislators debate measures that would require clinics to notify parents of a minor's request for contraception, Rachel K. Jones contends (see article) that "a more promising alternative…would be to support clinics in their efforts to improve parent-child communication." In a small, exploratory survey, Jones finds evidence that family planning clinics are making concerted efforts to involve parents in their minor children's reproductive health decisions. All clinics in the sample engaged in at least one activity intended to promote parent-child communication, and most engaged in more than one. Many appear committed to helping teenagers talk to parents about sexual health issues and to helping parents initiate conversations with youth.
•With the availability of drugs that can slow the progression of HIV to AIDS, patterns of unprotected sex among infected individuals are of great concern. Eric Rice and coauthors report (see article) that the prevalence of unprotected sex was twice as high in a sample of HIV- infected youth interviewed in 1999–2000, after the development of highly active antiretroviral therapy (HAART), as among a similar sample interviewed before the advent of HAART. In multivariate analyses, the characteristics associated with the likelihood of unprotected sex differed between the samples. Most striking, poor mental health emerged as a significant predictor of unprotected sex in the post-HAART sample overall and among infected youth not being treated with HAART—who, the analysts note, are the most infectious. The needs of young people suffering from both HIV and poor mental health, as Rice and colleagues point out, are complex and require the attention of targeted interventions. —The Editors