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Grant, community health centers, and migrant and rural health centers also help to provide reproductive health services in various ways.1
Title X of the Public Health Service Act was first authorized in 1970 and serves as the backbone of family planning services for many women in the United States. Title X authorizes project grants to public and private nonprofit organizations for the provision of family planning services to all who need and want them, including sexually active adolescents, but with a priority given to low-income persons. The program is buttressed by a training program for clinic personnel and has some community-based education activities as well. Federal monies are provided directly to state and local family planning providers, and state matching funds are not required. In 1990, more than 4,000 family planning clinics received $118 million in Title X support (Ku, 1993). During the 1980s, federal funding fell dramatically and the clinics became more dependent on state, local, and private resources (Gold and Daley, 1991). These family planning clinics served approximately 4.5 million women in 1991, an increase from 3.8 million women in 1981. The majority of family planning clinic clients are low-income women, and approximately one-third are adolescents. The average proportion of male clients served in family planning clinics is approximately 6 percent (Burt et al., 1994).
Medicaid is a national, publicly supported program that provides a unique 90 percent federal matching rate to state expenditures for the family planning care of women enrolled in the Medicaid program. Most public dollars spent on family planning are through the Medicaid program; federal and state expenditures in 1990 were approximately $270 million, serving an estimated 1.7 million clients, of whom 2 percent were men (Gold and Daley, 1991; Ku, 1993). In part because of the expansion in eligibility for pregnant and postpartum women, but primarily because of a rise in the number of people enrolled in Aid to Families with Dependent Children (AFDC), and therefore also in Medicaid, more women began using Medicaid to support contraceptive services in the mid- to late 1980s compared with the number in the 1970s and the early 1980s (Ku, 1993).
The impact of Title X and Medicaid, the two largest public programs, on unintended pregnancy has not been clearly defined, although a number of studies have tried to assess the effect of "publicly supported family planning programs" (which typically include the Title X and Medicaid programs) on various fertility
Another national program relevant to unintended pregnancy is the contraceptive research and development activities of the National Institute of Child Health and Human Development. The Institute of Medicine (1990) report Developing New Contraceptives, commented extensively on that research program; additional analysis is currently under way through another Institute of Medicine study (Applications of Biotechnology to Contraceptive Research and Development: New Opportunities for Public/Private Sector Collaboration) focused on how to best stimulate research in this important area.