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Reproductive Health Disparities: A Lifespan Approach
1. Leading The Quest For 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
Reproductive Health 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
Reproductive Health 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
Reproductive Health 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
Reproductive Health 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
Reproductive Health 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
The Women’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
The Women’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
Condition Total 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
Condition Total 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
The Women’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
Condition Total 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
Condition Total 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
Condition Total 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
Condition Total 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
Condition Total 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
The Women’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
Condition Total 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
Condition Total 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
Condition Total 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
The Women’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
29. KD Gregory 4/06
The Women’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
Post Reproduction 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
Post Reproduction 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
Post Reproduction 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
Post Reproduction 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
So What 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
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
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.
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
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
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
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.
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
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
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
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
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.
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.
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
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.
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
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.
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.