Although there seems to be an emerging consensus that the nation needs more primary care and general practitioners, specialization remains a more profitable and intellectually challenging option for many medical students, and it may well be many years before the supply of primary care and general practitioners catches up with the need. Nurse practitioners and advanced-practice nurses are being relied on in increasing numbers to provide primary care to patients, and many studies have indicated that the basic health care provided by nurses is of high quality (Mundinger, 1994). Nurses' effectiveness in promoting health, communicating with patients, adapting medical regimens according to patient preferences and environments, and using community resources make them prime candidates for encouraging contraceptive use as well. A recent survey confirmed their commitment to contraceptive access: a self-administered questionnaire surveying graduates of five reproductive health nurse practitioner programs in the United States revealed that 56 percent of the respondents were currently employed by a Title X agency (National Association of Nurse Practitioners in Reproductive Health, 1994). Even though many nurses are presently providing selected contraceptive services, the role that nurses play in providing access could undoubtedly be increased.

Bureaucratic Hurdles

In day-to-day life, the specific barriers to access outlined thus far, such as limited insurance coverage and insufficient provider training, can interact with each other and with additional obstacles to produce a bureaucratic tangle that undoubtedly limits access to contraception. After all, the medical services required to secure the more effective forms of contraception in the United States are embedded in the nation's general health care system, with its well-described problems of geographic maldistribution of providers, problems in locating transportation to service sites, bureaucratic delays in arranging for care, difficulty even in finding the telephone number to call for services, seeing different providers at each visit, absence of translators, long waits for appointments and in the waiting rooms once an appointment is in hand, and so forth. These general barriers are not detailed here because they have been well covered in previous reports from the Institute of Medicine (1994, 1988) and from many other sources.

Several case studies specific to contraceptive access illustrate the point, particularly the New York City study noted earlier. As described above, in December 1992 and January 1993, a team from the New York City Mayor's Advisory Council on Child Health called 115 service sites that ostensibly offer family planning care in the city to request an appointment for contraceptive services. In over one-third of the cases, even the English-speaking callers were not able to make an appointment at all, although this figure varied by type of



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