Rural U.S. women are less likely than city dwellers to receive preventive reproductive health care, and differences in availability of obstetrician-gynecologists may not always be the cause of the disparity, Cynthia H. Chuang and colleagues report in this issue of Perspectives on Sexual and Reproductive Health (page 78). In semistructured interviews, 19 primary care physicians in rural Pennsylvania acknowledged a shortage of obstetrician-gynecologists in their communities; however, they did not consider access to reproductive health care a problem. The real barriers to such care, in their view, are community norms that do not support family planning. At the same time, though, participants—most of whom were family practitioners or internists—did not actively promote reproductive health care. The researchers draw two main conclusions: Improving use of preventive reproductive health services in rural areas will entail more than expanding access; and primary care physicians need to be encouraged, and trained, to take "a more proactive role" in ensuring that women obtain appropriate care.
• Making oral contraceptives available over the counter would be a welcome change for many women, but it is a matter of concern among some, as Amanda Dennis and Daniel Grossman learned from focus group discussions and in-depth interviews with low-income women in the Boston area (page 84). In general, the women supported an over-the-counter switch. Nonetheless, they were concerned that out-of-pocket costs would increase and that some women (but not they themselves) would not be able to use the pill safely without a physician’s guidance. And over-the-counter availability would not change the fact that not all women want to use the pill. As the authors note, "Any move toward over-the-counter provision … should include an informational campaign highlighting the full range of methods available."
• Even if teenagers at high risk of STD infection understand the main strategies for preventing STD transmission, they may not use them. A sample of rural black youth in a focus group study conducted by Aletha Y. Akers and coauthors (page 92) said that abstinence simply is not a realistic goal in their world, strategies requiring partner cooperation are difficult to use and STD prevention is not paramount when young people make sexual decisions. They described alternative measures they take to reduce their risk, but these are not effective and, in some cases, could be harmful. The authors conclude that interventions are needed to help adolescents "identify opportunities to successfully employ … effective primary STD prevention strategies."
• In a qualitative study of health educators and clinicians in abortion clinics around the country (page 100), Jessica Morse and colleagues found general awareness that immediate postabortion provision of IUDs and implants is a safe, effective approach to preventing repeat unintended pregnancy. However, half of all clinics represented did not offer these methods, mainly for nonmedical reasons. Cost was the most commonly cited barrier, and logistical concerns were an impediment for some sites. "In this era of evidence-based medicine," the authors write, "this is an arena where clinical practice is deviating from the best evidence."
• Jennifer J. Frost and coauthors report (page 107) that in a nationwide sample of young adults, knowledge about contraceptive methods was one of the strongest predictors of contraceptive use and expectation of having unprotected sex. However, substantial proportions of the 18–29-year-olds surveyed demonstrated "serious gaps" in knowledge about the most common methods. The researchers conclude that "new educational strategies are urgently needed" to help young people understand the methods at their disposal and to take the necessary steps to avoid unintended pregnancy.
• State laws that restrict women’s access to abortion by requiring a waiting period, an ultrasound or, for minors, parental involvement purportedly are intended to ensure that women are making a fully informed choice that they will not regret. At one large clinic, however, Diana Greene Foster and colleagues found that most women were confident in their decision, and counselors detected no indication that they would likely experience regret or have difficulty coping down the road (page 117). Characteristics associated with women’s confidence in their decision included measures reflecting social support, general difficulty making decisions, and religious or moral concerns about abortion. Instead of "blanket regulations," the authors suggest, women seeking abortions need counseling from "caring, nonjudgmental" staff trained to address their complex, unique needs.
• Estimates based on data from the National Longitudinal Study of Adolescent Health, and reported by Sanyu A. Mojola and Bethany Everett (page 125), suggest that the prevalence of STD risk factors is greater among young adults who belong to sexual minority groups than among heterosexuals of the same race or ethnicity; it also appears to be higher among sexual-minority black and Hispanic young people than among heterosexual whites. As the authors note, although their estimates must be viewed with caution because the number of sexual-minority individuals in the sample was small, they point the way toward further research that is needed into the sexual health risks and needs of these apparently vulnerable populations.
• Studies based on regression analysis, a common analytic strategy in the social sciences, often inappropriately draw—or imply—causal conclusions. In a viewpoint article (page 134), Norman A. Constantine discusses the types of conclusions that can and cannot legitimately be drawn from regression analyses, as well as the kinds of studies that can and cannot properly be interpreted as demonstrating causal relationships. Constantine emphasizes that regression analysis is a tool—a good tool for some purposes, but a flawed one for others—and that it takes more than use of a good tool to arrive at a solid causal conclusion.
—The Editors