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Reproductive Health Disparities: A Lifespan Approach
- 1. Leading The QuestFor Health™ Reproductive Health Disparities” A Lifespan Approach Kimberly D. Gregory MD, MPH Associate Professor Cedars Sinai Medical Center David Geffen School of Medicine & UCLA School of Public Health
- 2. KD Gregory 4/06 ReproductiveHealth Disparities Why should we care? What is the magnitude of the problem? Over 90% of US women expect to give birth at least once during their lifetime 4.1 million births in US 60% or more additional pregnancies=tabs, sabs, SB Approximately 6.4 million pregnancy related events Significant issue with regard to health care costs, health care resources, personal joy/suffering
- 3. KD Gregory 4/06 ReproductiveHealth Disparities Pregnancy is a significant event in a woman’s life and has a profound impact on her health and well-being Emerging data that the health and well-being of a woman sets the stage for the health and well-being of her offspring, and ultimately her family
- 4. KD Gregory 4/06 ReproductiveHealth Disparities Policy implications Representative indicators specific to women’s health are widely used to reflect the health of a population (e.g. MMR, IMR) US has low MMR 11.5/100,000 vs relatively high IMR 6.9/1000 live births —Ranks 25th internationally Hence, measuring, monitoring and reporting indicators of women’s health should be a national priority
- 5. KD Gregory 4/06 ReproductiveHealth Disparities Women’s Health = Pregnancy Traditional indicators Fertility MMR Onset, adequacy of prenatal care Fetal and infant mortality Prematurity Low Birth Weight
- 6. KD Gregory 4/06 ReproductiveHealth Disparities Women’s Health = Pregnancy Review recognized disparities in pregnancy and women’s health related to women’s reproductive health conditions Frame the discussion within the context of a women’s reproductive life span Provides an opportunity to identify the gaps in knowledge about women’s health outcomes, and to begin to conceptualize potential solutions Will not address chronic medical conditions
- 7. KD Gregory 4/06 TheWomen’s Health Continuum: A Lifespan Approach Health Maintenance Post Reproductive Years Pre-pregnancy Planning Pregnancy Postpartum Newborn (a new life*) *Fetal origins of adult diseases Puberty Preconception Pregnancy Postpartum Newborn Interconception Menopause Postreproductio n
- 8. KD Gregory 4/06 TheWomen’s Health Continuum: A Lifespan Approach Health Maintenance Post Reproductive Years Pre-pregnancy Planning Pregnancy Postpartum Newborn (a new life*) *Fetal origins of adult diseases Conditions are not exhaustive or mutually exclusive to any time period No attempt to address chronic diseases
- 9. KD Gregory 4/06 Puberty ConditionTotal White Black Hispanic Asian Other Puberty (X age, years) 12.7 12.0 --- >white >white •Trend toward earlier maturation in AA girls as compared with Caucasian girls •AA girls enter puberty 1 to 1.5 yrs earlier (age 8 to 9 years) and start menses 8.5 months earlier (12.1 yrs) •Asians, American Indians comparable (or later) than Caucasian •MA enter puberty at the same time as Caucasian girls, but delayed maturation: reach adult stages later
- 10. KD Gregory 4/06 Puberty ConditionTotal White Black Hispanic Asian Other Puberty (X age, years) 12.7 12.0 --- >white >white •Are these “Differences” or “Disparities”? •Environmental factors (lead, nutrition, obesity) influence maturation, and these risk factors are disproportionately distributed •Important clinical, educational, and social implications •Referrals for precocious or delayed puberty •Anticipatory guidance “what to expect when” •Determining time and age appropriate sex education
- 11. KD Gregory 4/06 Puberty& Preconception Condition Total White Black Hispanic Asian Other Puberty (X age, years) 12.7 12.0 --- >white >white Current Contracep tion use 46.6 66.6 62.2 58.9 --- --- STD/PID 8.0 8.0 11.0 --- --- Teen pregnancy 45.9 28.5 68.3 83.4 18.3 53.8 NA Abortion 25.6 17.1 52.9 26.1 --- ---
- 12. KD Gregory 4/06 Preconception Maternal health during pregnancy is directly related to maternal health prior to pregnancy Emerging emphasis on preconception care and health maintenance Women seen by providers during this time should be considered “at risk” for conception Each visit viewed as contraception or preconception visits — Provide health promotion or primary preventive services — Condoms decrease STD’s (and pregnancy) — Contraception decrease unintended pregnancies (50% of pregnancies); delay first births, promote birth spacing by at least 2 years
- 13. KD Gregory 4/06 Preconception CDC individual level actions by health practitioners to reduce maternal and infant mortality and promote the health of all childbearing-aged women at preconception/interconception visits — Screening for preexisting chronic conditions and health risks — Counseling about contraception and access to effective family planning to prevent unintended pregnancy & unnecessary abortion — Counseling about good nutrition including iron, folic acid — Advise re: regular exercise, ETOH, smoking, drugs
- 14. KD Gregory 4/06 TheWomen’s Health Continuum: A Lifespan Approach Health Maintenance Post Reproductive Years Pre-pregnancy Planning Pregnancy Postpartum Newborn (a new life*) *Fetal origins of adult diseases
- 15. KD Gregory 4/06 Pregnancy 90% of US women expect to give birth at least once during their lifetime Good opportunity for health promotion and primary preventive services — May be the only period where some women have coverage — Most women are motivated to change behaviors to optimize pregnancy outcome — Studies suggest women who seek prenatal care sustain interactions with the health care system for their newborn (e.g. well baby checks, immunizations, etc)
- 16. KD Gregory 4/06 Pregnancy ConditionTotal White Black Hispanic Asian Other Prenatal care, 1st trimester 83.2 85.0 74.3 74.4 75.6 MA 79.1 PR 91.8 CU 77.4 CA 84.0 90.1 JA 87.0 CH 85.0 FIL 82.7 OT 79.1 HA 69.3 NA No PNC 3.7 3.2 6.5 5.9 8.2 6.5
- 17. KD Gregory 4/06 Pregnancy ConditionTotal White Black Hispanic Asian Other Fertility rate (/1000 reproductive age woman) 67.5 58.0 69.3 107.4 69.4 70.4 Birth rate (/1000 population) 3.7 3.2 6.5 5.9 8.2 6.5 •All ethnic groups have higher fertility and birth rates than Caucasians •Changing population demographics makes understanding differences important with regard to prevention/intervention strategies and health care costs and resource utilization
- 18. KD Gregory 4/06 Pregnancy ConditionTotal White Black Hispanic Asian Other Miscarriages (% clinically recognized) 13.8 13.8 13.5 --- --- -- Ectopics 1.3 1.2 1.6 --- --- ---
- 19. KD Gregory 4/06 Pregnancy ConditionTotal White Black Hispanic Asian Other Maternal mortality 11.5 6.0 25.1 10.3 11.3 12.2 NA Pregnancy comps GD 2.9 HTN 3.9 2.7 4.2 2.8 2.8 2.9 3.9 --- --- Cesarean rate 26.1 25.9 27.6 25.2* 36.9 CU 25.0 23.1 Age >35 48.3 48.5 39.4 60.3 73.1 39.8
- 20. KD Gregory 4/06 Pregnancy ConditionTotal White Black Hispanic Asian Other Infertility 15.0 --- --- --- --- --- Primary Etiology Ovarian 46.5 14.5 Male fx 24.5 11.5 Other 15.3 3.6 Tubal 13.8 41.0 Unknown 11.0 12.8 Endometr ial 4.7 2.6 Sterilized 4.6 25.6
- 21. KD Gregory 4/06 TheWomen’s Health Continuum: A Lifespan Approach Health Maintenance Post Reproductive Years Pre-pregnancy Planning Pregnancy Postpartum Newborn (a new life*) *Fetal origins of adult diseases
- 22. KD Gregory 4/06 Newborn ConditionTotal White Black Hispanic Asian Other Perinatal mortality --- 1.9 4.7 1.9 --- --- Fetal deaths 6.6 5.6 12.4 --- --- --- Neonatal Mortality 4.6 3.8 9.4 3.7 --- --- Infant Mortality 6.9 5.7 14.1 5.6 5.1 9.0 NA
- 23. KD Gregory 4/06 Newborn ConditionTotal White Black Hispanic Asian Other Infant Mortality 6.9 5.7 14.1 5.6 5.1 9.0 NA 5.5 MA 8.1 PR 4.3 CU 4.9 CA 3.8 JA 3.5 CH 5.9 FIL 5.2 OTH 8.7 HA Diversity among subtypes with Puerto Ricans and Hawaiians having intermediate rates Compared to AA and Caucasians. Cubans, Japanese, and Chinese = Caucasians
- 24. KD Gregory 4/06 Newborn ConditionTotal White Black Hispanic Asian Other Preterm birth 12.1 11.1 17.5 11.6* 10.4* 13.1 NA Low Birth Weight 7.8 6.8 13.3 7.8* 7.8* 7.2 VLBW <1500 g 1.5 1.2 3.1 1.5* 1.1* 1.3 IUGR at term 2.9 2.5 5.2 4.0 --- --- * Variation in rates by different population subtypes
- 25. KD Gregory 4/06 TheWomen’s Health Continuum: A Lifespan Approach Health Maintenance Post Reproductive Years Pre-pregnancy Planning Pregnancy Postpartum Newborn (a new life*) *Fetal origins of adult diseases
- 26. KD Gregory 4/06 Postpartum& Interconception Health Maintenance Opportunity for further prevention, screening and interventions Postpartum visit-increased emphasis by ACOG & NCQA Prevention, detection, and early treatment of complications (e.g. hemorrhage, eclampsia, infection and postpartum depression) Information and education (child care, breast feeding, nutrition, and contraception WHO Technical Working Group Postpartum Care suggest one visit isn’t enough and advocates for 6 hours, 6 days, 6 weeks, and 6 mos as critical time when provider visits might be valuable in identifying maternal or neonatal health needs or complications
- 27. KD Gregory 4/06 Postpartum& Interconception Health Maintenance Condition Total White Black Hispanic Asian Other Breast- feeding 55.2 59.1 25.1 62.2 --- --- Depression 8.0 Fibroids (/1000 women) 9.2 8.2 16.9 --- --- --- Chronic GYN (/1000 women) 97.1
- 28. KD Gregory 4/06 InterconceptionHealth Maintenance Gynecologic disorders —Menstrual disorders (most common) —Adnexal conditions (cysts) —Fibroids (20% of women; age, AA) —Endometriosis —Chronic pelvic pain
- 29. KD Gregory 4/06 TheWomen’s Health Continuum: A Lifespan Approach Health Maintenance Post Reproductive Years Pre-pregnancy Planning Pregnancy Postpartum Newborn (a new life*) *Fetal origins of adult diseases
- 30. KD Gregory 4/06 PostReproduction and Menopause Study of Women’s Health Across the Nation (SWAN) —Median age 51.4 (adjusted for smoking education, marital status, heart disease, parity, race and ethnicity, employment, prior OC’s) —Current smoking, lower SES associated with earlier menopause —Parity, prior OC use and Japanese race/ethnicity associated with later menopause
- 31. KD Gregory 4/06 PostReproduction and Menopause Significant racial, ethnic, and sociocultural differences in how menopause is experienced and perceived Japanese and Chinese women reported fewest symptoms Hispanic women reported the most AA more likely to report hot flashes and vaginal dryness White women more likely to report urine leakage and difficulty sleeping Symptoms mediated by BMI, smoking and SES
- 32. KD Gregory 4/06 PostReproduction and Menopause Condition Total White Black Hispanic Asian Other Menopause Median age 51.4 51.4 51.4 51.0 51.8 JA 51.4 CH --- Pelvic prolapse (/1000) 2.1 Incontinence GUI % 59 29 8 14 DI% 15 Caucasians have higher rates of prolapse, incontinence—likely ascertainment Bias; Caucasians more likely to seek treatment for these conditions
- 33. KD Gregory 4/06 PostReproduction and Menopause Condition Total White Black Hispanic Asian Other Cancer Incidence Breast 135.8 140.8 120.8 83.6 102.0 54.4 Cervix 9.1 8.8 12.3 16.1 8.6 --- Ovary 16.7 17.6 11.8 12.4 13.1 --- Uterus 24.3 25.6 17.3 15.3 18.0 --- Cancer Deaths Breast 27.2 35.9 17.9 12.5 14.9 Cervix 2.7 5.9 3.7 2.9 2.9 Ovary Uterus
- 34. KD Gregory 4/06 SoWhat Can Be Done To Close The Gap? Health and Function Disease Health Care Physical Environment Genetic Endowment Well-Being Prosperity Individual Response - Behavior - Biology Social Environment Dynamic interaction between social and medical forces Some of the differences can be accounted for by behavior—potentially modifiable Will require a strategic combination of prevention and intervention across the life span and at multiple levels (individual, family/community, work, public policy) to close the gap in pregnancy and women health outcomes
- 35.
Editor's Notes
- #8 Protective behaviors and risk factors throughout the course of a woman’s life influence her health during pregnancy, and recent studies suggest that these influences start in uteru. Hence the health of any woman is influenced by her genetic makeup, her own in utero exposures, the effecdt of her health during childhood and adolescece and her behaviors prior to pregnancy. Additional enviormental stressors such as early infant experiences and social conditions (race, ethnicity, pevoerty, stress) all have a cumulative impact on the course of an individual’s health from adolescence to death. Reproductive halth outcomes include factors pertinent to multiple time periods: puperty, preconception, pregnancy, postpartum and newborn, interconception, menopause, and postreproduction
- #9 No attempt to address chronic diseases such as obesity, diabetes, hypertension or heart disease, all of which are common in women and more likely to occur among minority and/or poor populations. Emerging data suggest that some of these condition are preprogrammed in utero due to genetics, or exacerbated by life circumstances related to personal, nutritional, occupational, or enviromental stressors, and personal behaviors. Likewise will not discuss rhematologic, immunologic orneurologic diseases that also have a female preponderance, nor will I address domestic violence, injury and depression.
- #10 Population based studies in the US have found a consistent trend toward earlier maturation in AA girls as compared with Caucasians. AA girls enter puberty 11.5 years earlier
- #11 Population based studies in the US have found a consistent trend toward earlier maturation in AA girls as compared with Caucasians. AA girls enter puberty 11.5 years earlier
- #12 Population based studies in the US have found a consistent trend toward earlier maturation in AA girls as compared with Caucasians. AA girls enter puberty 11.5 years earlier
- #15 No attempt to address chronic diseases such as obesity, diabetes, hypertension or heart disease, all of which are common in women and more likely to occur among minority and/or poor populations. Emerging data suggest that some of these condition are preprogrammed in utero due to genetics, or exacerbated by life circumstances related to personal, nutritional, occupational, or enviromental stressors, and personal behaviors. Likewise will not discuss rhematologic, immunologic orneurologic diseases that also have a female preponderance, nor will I address domestic violence, injury and depression.
- #17 Most widely covered indicator. Varies by race/ethnicity. AA, Hispanci, and Native american women have lower prenatal care rates than White or Asian women. Important when talking about widely heterogeneous cultures: subtypes have different rates, Cubans have rates comparable to whites, hereas MA, Peurto Ricans more like AA
- #18 Most widely covered indicator. Varies by race/ethnicity. AA, Hispanci, and Native american women have lower prenatal care rates than White or Asian women. Important when talking about widely heterogeneous cultures: subtypes have different rates, Cubans have rates comparable to whites, hereas MA, Peurto Ricans more like AA
- #19 Most widely covered indicator. Varies by race/ethnicity. AA, Hispanci, and Native american women have lower prenatal care rates than White or Asian women. Important when talking about widely heterogeneous cultures: subtypes have different rates, Cubans have rates comparable to whites, hereas MA, Peurto Ricans more like AA
- #20 Population based studies in the US have found a consistent trend toward earlier maturation in AA girls as compared with Caucasians. AA girls enter puberty 11.5 years earlier
- #21 1995 National Survey of Family Growth estimated 15% of reproductive age women have used infertiity services. No definitive source for differences in rates of infertility. One regional study from Detroit indicated that referral patterns mirror the city demographics. However there is data to suggest that the leading patient level causes of infertility differ by race ethnicity. Has only been characterized for whites and blacks, but it is ovarian dysfunction and male factor for whites and tubal factors or prior sterilization for AA.
- #22 No attempt to address chronic diseases such as obesity, diabetes, hypertension or heart disease, all of which are common in women and more likely to occur among minority and/or poor populations. Emerging data suggest that some of these condition are preprogrammed in utero due to genetics, or exacerbated by life circumstances related to personal, nutritional, occupational, or enviromental stressors, and personal behaviors. Likewise will not discuss rhematologic, immunologic orneurologic diseases that also have a female preponderance, nor will I address domestic violence, injury and depression.
- #23 Population based studies in the US have found a consistent trend toward earlier maturation in AA girls as compared with Caucasians. AA girls enter puberty 11.5 years earlier
- #24 Well known fact that AA experience significantly higher IMR rates, and preterm birth rates, almost 3x that of Whites. Hispanics and Asians have comparable rates to whites, but when stratified by subpoplations, these groups demonstrate significant variation. Puerto Ricans in particular seem to parallel AA. Hawaiians tend to have the worse outcome among Asian Pacific Islanders. Theories include decreased access, lowere SES, increased biologic tendencies toward infection, stress and strain, lack of social support, and racism (as reflected by the amount of melanin in an individuals skin) The perisistent disparity and the increasing scientific association between antenatal and birth events as contirbuting factors in an indivisual ultimate health have lead to a heightened sensitivy of the need to narrow this gap which constitues a major national public health priority.
- #25 Population based studies in the US have found a consistent trend toward earlier maturation in AA girls as compared with Caucasians. AA girls enter puberty 11.5 years earlier
- #26 No attempt to address chronic diseases such as obesity, diabetes, hypertension or heart disease, all of which are common in women and more likely to occur among minority and/or poor populations. Emerging data suggest that some of these condition are preprogrammed in utero due to genetics, or exacerbated by life circumstances related to personal, nutritional, occupational, or enviromental stressors, and personal behaviors. Likewise will not discuss rhematologic, immunologic orneurologic diseases that also have a female preponderance, nor will I address domestic violence, injury and depression.
- #30 No attempt to address chronic diseases such as obesity, diabetes, hypertension or heart disease, all of which are common in women and more likely to occur among minority and/or poor populations. Emerging data suggest that some of these condition are preprogrammed in utero due to genetics, or exacerbated by life circumstances related to personal, nutritional, occupational, or enviromental stressors, and personal behaviors. Likewise will not discuss rhematologic, immunologic orneurologic diseases that also have a female preponderance, nor will I address domestic violence, injury and depression.