Charting a Course for the Future of Women’s and Perinatal Health
Volume 1: Concepts, Findings, and Recommendations
ISBN 1-893692-02-7
C
harting
a Course for the
Future of Women’s
and Perinatal Health
Volume 1: Concepts, Findings, and Recommendations
Holly Grason, John Hutchins, and Gillian Silver
Editors
A Collaborative Initiative of the Women’s and Children’s Health Policy Center
Department of Population and Family Health Sciences, The Johns Hopkins
University and the Maternal and Child Health Bureau Health Resources and
Services Administration, U.S. Department of Health and Human Services
C
harting a Course for the
Future of Women’s and Perinatal Health
Volume I: Concepts, Findings, and Recommendations
Holly Grason, John Hutchins, and Gillian Silver
Editors
Women’s and Perinatal Health Policy Working Group
A Collaborative Initiative
of the
Women’s and Children’s Health Policy Center
Department of Population and Family Health Sciences
Johns Hopkins School of Public Health
and the
Maternal and Child Health Bureau
Health Resources and Services Administration
U.S. Department of Health and Human Services
March 1999
Cite as:
Grason HA, Hutchins JE, Silver GB, eds. 1999. Charting a Course for the Future of Women’s
and Perinatal Health: Volume I — Concepts, Findings, and Recommendations. Baltimore, MD:
Women’s and Children’s Health Policy Center, Johns Hopkins School of Public Health.
Charting a Course for the Future of Women’s and Perinatal Health: Volume I — Concepts,
Findings, and Recommendations is not copyrighted. Readers are free to duplicate and use all or
part of the information contained in this publication. In accordance with accepted publishing standards, the Johns Hopkins Women’s and Children’s Health Policy Center requests acknowledgment,
in print, of any information reproduced in another publication.
The Women’s and Children’s Health Policy Center
Department of Population and Family Health Sciences
Johns Hopkins School of Public Health
624 North Broadway
Baltimore, MD 21205
Tel: 410/502-5443
Fax: 410/955-2303
Internet: http://www.med.jhu.edu/wchpc
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ISBN 1-893692-02-7 (Volume I)
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Single copies of this publication are available at no cost from the National Maternal and
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Development of this document was supported by cooperative agreement (5 T78 MC 0000503) with the Maternal and Child Health Bureau, Health Resources and Services Administration, U.S.
Department of Health and Human Services.
Foreword
T
he dimension and impact of current societal and environmental conditions bring the
Nation face-to-face with critical new challenges for women’s and perinatal health. These
challenges stem from altered approaches for financing and delivering health care, advances
in medical technology, devolution of responsibility to State and local communities, trends toward
privatization of governmental services, and reexamination of public health functions, coupled with
a growing emphasis on women’s health. Not infrequently, women’s health and perinatal health
have been addressed as separate entities; recently, this perspective has been called into question.
These intense changes, present emphases, and the anticipation of a new century prompted the initiation of Charting a Course for the Future of Women’s and Perinatal Health, a collaborative effort of the Johns Hopkins University Women’s and Children’s Health Policy Center and the
Health Resources and Services Administration’s Maternal and Child Health Bureau. Recognizing that
prior paradigms no longer serve us well, this work was developed to assess the health needs of
women of reproductive age and to formulate recommendations for future directions in policy, practice, and research.
The Bureau and the Center are pleased to present a two-volume compendium that reflects
findings from the literature and the opinions of experts utilized throughout the initiative. This compendium is distinguished by two features: 1) its examination of perinatal health within the context
of women’s overall health across the reproductive lifespan; and 2) its public health orientation,
addressing population health in the context of social, environmental, and behavioral factors.
Volume I reports on the conceptual foundation, findings, and a wide array of recommendations for
change. Volume II presents the background papers for the initiative which offer detailed literature
reviews of selected health issues.
I believe this document will be useful in educating constituencies, developing and implementing new policies and practices, and guiding efforts to monitor the impact of systems changes
on women of reproductive age. I also hope that Charting a Course for the Future of Women’s and
Perinatal Health will stimulate extensive action among maternal and child health and women’s
health professionals, advocates, and policymakers to advance women’s and perinatal health for this
and future generations.
Peter C. van Dyck, MD, MPH
Acting Associate Administrator for
Maternal and Child Health
Maternal and Child Health Bureau
iii
iv
Contents
Page
Foreword........................................................................................................................................................iii
Acknowledgments.................................................................................................................................vii
Chapter I: Toward a New Vision of Women’s Health
Introduction: New Challenges and Opportunities....................................................... 1
Scope of the Initiative................................................................................................... 2
Guiding Principles...........................................................................................................2
The Evolution of the Field of Women’s Health........................................................... 3
The Social Context of Women’s and Perinatal Health................................................ 5
Chapter II: Key Topics in Women’s and Perinatal Health — Findings
from the Literature
Introduction.....................................................................................................................9
Health Care Services and Systems for Women of Reproductive Age........................10
Public Health Roles Promoting the Health and Well-Being of Women.....................13
Women’s Reproductive Health and Their Overall Well-Being...................................18
Pregnancy Planning and Unintended Pregnancy........................................................21
Issues in Pregnancy Care..............................................................................................24
Women’s Experience of Chronic Diseases...................................................................29
Depression in Women...................................................................................................31
Abuse Against Women by Their Intimate Partners.....................................................34
The Nutritional Status and Needs of Women of Reproductive Age..........................36
Women’s Physical Activity in Leisure, Occupational, and Daily Living Activities.....38
Effects of Drug and Alcohol Use on Women’s and Perinatal Health........................40
Effects of Smoking on Women’s and Perinatal Health...............................................43
Cross-Cutting Issues and Implications .........................................................................44
Chapter III: Recommendations for the Future of Women’s and Perinatal
Health
Introduction ...................................................................................................................47
Social Policies................................................................................................................48
Surveillance and Quality Assurance.............................................................................50
Service Availability, Coordination, and Organization .................................................54
Financing of Health Programs and Services................................................................57
Health Communication and Education Services......................................................... 59
Development of Workforce Competency and Capacity.............................................61
Appendix......................................................................................................................................65
Participants — Charting a Course for the Future Meeting of Experts, April 1998
References.....................................................................................................................................................73
v
vi
Acknowledgments
T
his initiative seeking to uncover new viewpoints and stimulate new partnerships towards
the goal of a women’s and perinatal health policy agenda provided us enriching opportunities to work with many highly talented researchers, policy analysts, providers, and
promoters of health care for women from across the United States. Regardless of their post or specific role in the Charting a Course for the Future of Women’s and Perinatal Health initiative, they
are all advocates, committed to improving the health and quality of life for America’s 135 million
women, and for those to be born in the next century. Their contributions were essential to the
development of this publication and its companion documents. We will long remain grateful for
their generous assistance and support.
Participants in the April 1998 working meeting were particularly critical in shaping our
work. These individuals, representing a diverse array of local, state, and national level public agencies, policy research institutions, and professional and advocacy organizations, are listed in the
Appendix. Not only did they engage in extensive deliberations over the two days of the meeting,
they also reviewed preliminary versions of recommendations documents, and provided insightful
feedback and suggestions for refinement. The quality of the commentary we received, both in April
and in subsequent communications, was impressive and infinitely helpful. The extra efforts of those
who led workgroup discussions and presented their synthesized findings are particularly appreciated; these individuals were Maribeth Badura, Donna Barber, Claire Brindis, Sally Fogerty, David
Gagnon, Bernard Guyer, Ellen Hutchins, Donna Hutten, Lisa Kaeser, Cynthia Minkovitz, Helen
Rodriguez-Trias, William Sappenfield, Richard Schwarz, Terrence Smith, Donna Strobino, Carol
Weisman, Deanne Williams, and Gail Wilson. Our appreciation also is extended to our colleagues
who presented their reflections on the deliberations at the conclusion of the meeting — Catherine
Hess, Milton Kotelchuck, and Sheryl Burt Ruzek.
Special recognition and thanks are due our colleagues who served as reviewers for the thirteen papers that provide the foundation for our work. Their perspectives on draft documents and
suggestions regarding additional information sources strengthened enormously the comprehensiveness and quality of this work of the Women’s and Perinatal Health Policy Working Group. In this
regard, we thank the following individuals: Mary Applegate, MD, MPH (New York State Department
of Health); Claire Brindis, DrPH (University of California, San Francisco); Christi Bristow, RN, MN
(Washington State Department of Health); Martha Bruce, PhD, MPH (Cornell Medical College);
Trudy Bush, PhD (University of Maryland); Wendy Chavkin, MD, MPH (Columbia University);
Carolyn Clancy, MD (Agency for Health Care Policy and Research, DHHS); Sue Calvert Finn, PhD,
RD (Ross Laboratories); Sally Fogerty, BSN, MEd (Massachusetts Department of Public Health); Julie
Gazmararian, PhD (Prudential Center for Health Care Research); Charlotte Gish, CNM, MSN (U.S.
Public Health Service, Region VIII); Arden Handler, DrPH (University of Illinois); Rosemarie Henson
(Centers for Disease Control and Prevention, DHHS); William Hollinshead, MD, MPH (Rhode Island
Department of Health); Corinne Housten, MD, MPH (Centers for Disease Control and Prevention,
DHHS); Ellen Hutchins (Maternal and Child Health Bureau, HRSA, DHHS); Lisa Kaeser, JD (The Alan
Guttmacher Institute); Helene Kent, RD, MPH (Colorado Department of Public Health and
Environment); Debra Krummel, PhD, RD (West Virginia University); Paula Lantz, PhD (University of
vii
Michigan); Nancy Maddox, MPH (Association of Maternal and Child Health Programs); Sheryl Burt
Ruzek, PhD, MPH (Temple University); Nan Streeter, MS, RN (Utah Department of Health); Polly
Taylor, CNM, MPH, ARNP (Washington State Department of Health); Deborah Klein Walker, EdD
(Massachusetts Department of Public Health); Lynne Wilcox, MD, MPH (Centers for Disease Control
and Prevention, DHHS); Judy Wilson, MPH, RD (DC Commission on Public Health); and Deborah
Rohm Young, PhD (Johns Hopkins University).
As always with our work, this publication would not be possible without the contributions
of a talented and committed team of staff and students at the Johns Hopkins Women’s and
Children’s Health Policy Center. Lori Friedenberg and Kristie Susco coordinated the many meetings
— internal and external — wherein policy considerations were debated and our thinking and writing refined. These women also spent countless hours in libraries and at their computers unearthing
and organizing source documents for the reviews. Two students at the Johns Hopkins School of
Public Health also deserve special recognition for assisting the Working Group in specific research
and writing tasks — Ms. Kendra Rothert, MHS (chapter on Women’s Reproductive Health), and Ms.
Sarah Inglas-Baldy, RN (Issue Summaries). WCHPC Secretary, Jackie Tyson, was invaluable throughout, providing capable hands in all aspects of the initiative.
The initiative was funded by the Maternal and Child Health Bureau, Health Resources and
Services Administration, DHHS, under Title V of the Social Security Act. Federal project leadership for
this entire effort was provided by Ann M. Koontz, CNM, DrPH, to whom we are greatly indebted.
Holly Grason, John Hutchins and Gillian Silver for the
Women’s and Perinatal Health Policy Working Group
viii
Women’s and Perinatal Health Policy Working Group
Katherine M. Baldwin, MSW : Ms. Baldwin is a Project Manager at the Johns Hopkins Women’s and
Children’s Health Policy Center.
Yvonne Bronner, ScD, RD, LD : Dr. Bronner is an Assistant Professor and a Nutritionist within the
Department of Population and Family Health Sciences, Johns Hopkins School of Public Health.
Charlyn E. Cassady, BSN, MEd, PhD : Dr. Cassady is a Research Associate in the Department of Population
and Family Health Sciences, Johns Hopkins School of Public Health.
Holly Allen Grason, MA: Ms. Grason is Director of the Women’s and Children’s Health Policy Center, and
an Associate Scientist on the faculty of the Department of Population and Family Health Sciences, Johns
Hopkins School of Public Health.
Bernard Guyer, MD, MPH: Dr. Guyer is Professor and Chair of the Department of Population and Family
Health Sciences at the Johns Hopkins School of Public Health.
Melissa Hawkins, MHS: Ms. Hawkins is a doctoral candidate in the Department of Population and Family
Health Sciences, Johns Hopkins School of Public Health.
John E. Hutchins: Mr. Hutchins is Senior Editor for the National Campaign to Prevent Teen Pregnancy and
an independent communications consultant.
Ann M. Koontz, CNM, DrPH: Dr. Koontz is Associate Director for Perinatal Policy in the Division of Healthy
Start, Maternal and Child Health Bureau, Health Resources and Services Administration, DHHS.
Cynthia Minkovitz, MD, MPP : Dr. Minkovitz holds faculty appointments in both the Department of
Population and Family Health Sciences, School of Public Health and in the School of Medicine
Department of Pediatrics, Johns Hopkins University.
Dawn Misra, PhD : Dr. Misra is an Assistant Professor in the Department of Population and Family Health
Sciences, Johns Hopkins School of Public Health.
Wanda Nicholson, MD, MPH: Dr. Nicholson is Director, Community-Based Obstetrics and Gynecology and
an Assistant Professor in the Department of Obstetrics and Gynecology, Johns Hopkins School of Medicine.
Patricia O’Campo, PhD : Dr. O’Campo is an Associate Professor in the Department of Population and
Family Health Sciences, Johns Hopkins School of Public Health.
Virginia Poole, MA: Ms. Poole is a doctoral candidate in the Department of Health Policy and
Management, Johns Hopkins School of Public Health.
Marjory Ruderman: Ms. Ruderman is a Project Director at the Johns Hopkins Women’s and Children’s
Health Policy Center.
Gillian B. Silver, MPH: Ms. Silver is a Research Assistant for the Johns Hopkins Women’s and Children’s
Health Policy Center.
Donna M. Strobino, PhD : Dr. Strobino is a Professor in the Department of Population and Family Health
Sciences, Johns Hopkins School of Public Health.
Carol Weisman, PhD : Dr. Weisman is a Professor in the Department of Health Management and Policy
and Director of the Interdepartmental Concentration in Reproductive and Women’s Health, University of
Michigan School of Public Health.
ix
x
C
hapter I
Toward A New Vision of Women’s Health
Introduction: New Challenges and Opportunities
T
he turn of the century offers an opportune time to take stock of the current state of the
field of women’s and perinatal health and to make plans for the future. Women’s and
perinatal health have seen many changes this century, particularly in the last thirty years,
reflecting social, cultural, and economic transformations in the lives of women. Recent trends in
women’s demographics — including their educational attainment, employment status, reproduction,
family composition, and access to health care — point to an increasingly complex context influencing women’s health. This context is marked by women’s multiple roles as workers, parents, and
caretakers, and by health care and social welfare systems that have not been sufficiently responsive
to women’s unique needs. Historically divergent perinatal health and women’s health agendas further complicate current and emerging issues.
In the last ten years, the field of women’s and perinatal health has been confronted by a
host of new challenges and opportunities: a rapidly changing health care delivery system driven by
cost containment and reduced public health care expenditures, social welfare policy reforms that
profoundly alter the lives of poor women and children, continuing trends toward devolving responsibility for health and social programs from the federal government to the states and from states to
communities, and a resurgence of women’s activism that has changed health and research policies
and priorities. How should the field of women’s and perinatal health respond to these emerging
issues in the next decade? How should it work to ensure that the health of women is guaranteed?
The Women’s and Children’s Health Policy Center (WCHPC) at the Johns Hopkins
University School of Public Health, in collaboration with the federal Maternal and Child Health
Bureau (MCHB), has reviewed the current state of women’s and perinatal health and invited experts
to help develop recommendations on health policy, quality assurance, organization and financing
of services, education, workforce development, and research for the coming decade. A unique feature of this initiative is its examination of perinatal health within the broader context of women’s
overall health. For too long, perinatal health has been seen in isolation without fair consideration of
the complex and long-term interplay of health across a woman’s lifespan. Not only has this created
1
Charting a Course for the Future of Women’s and Perinatal Health
artificial distinctions related to women’s reproductive and non-reproductive health, but it has meant
that not enough attention has been paid to women’s health outside of perinatal issues. Moreover, a
special contribution of the initiative is found in its public health orientation, one that seeks to
address population health in the context of social, environmental, and behavioral factors.
Scope of the Initiative
The WCHPC’s assessment of the field included reviewing published research, program
reviews, and policy reports on women’s physical health, mental health, and health behaviors, and
on the effects of health services, systems, structures, organization, and financing on women’s health.
Literature specific to perinatal health was incorporated within the broader context of women’s
health. The WCHPC Women’s and Perinatal Health Policy Working Group (listed on page ix) prepared 13 papers on topics ranging from smoking to pregnancy care, from domestic violence to
chronic diseases. These papers discuss epidemiological trends, predictors of health field and risk
factors, interventions, and policy and research implications. These papers, which are summarized in
Chapter II of this volume, are published in their entirety in a companion publication, Charting a
Course for the Future of Women’s and Perinatal Health: Volume II — Reviews of Key Issues.
In the spring of 1998, MCHB and WCHPC convened a working meeting of women’s and
perinatal health professionals, policymakers, and advocates to identify the most pressing health concerns of women of reproductive age. Drawing on the reviews of the literature, meeting participants
identified changes that need to be made in health policy, services, and systems in order to ensure
continuous improvement in women’s and perinatal health. These changes form the basis of the recommendations in Chapter III.
To set the stage for the topic reviews and the policy and research recommendations, this
chapter outlines the philosophical principles that guided this initiative; describes briefly the history
of women’s and perinatal health field; and offers recent demographic data on women’s health, education, employment and economic status, reproductive health behaviors, family composition, and
access to health care.
Guiding Principles
Certainly the lives of American women — at home and at work — have changed dramatically in the past several decades, challenging the field of women’s health to expand its understanding of the meaning of women’s health. Moreover, this century has seen the philosophy of
health care for women evolve from a reproduction-centered medical model to one that increasingly describes women’s health in terms of the totality of their experience across the lifespan, including their expanded social and economic roles and the influence of culture, psychology, and social
factors — in other words, a biopsychosocial model of women’s health. However, even today,
women’s health often is defined in terms of how it differs from men’s health. A women-centered
conception of health, on the other hand, begins with an understanding of the health needs of
women and of how social factors influence their health. This view goes beyond recognizing biological differences to consider gender-based social and economic inequities that affect health. It also
recognizes that health is more than the absence of disease or disability; it is the maintenance of
physical health and psychological and social well-being. In this view, gender becomes a key variable in understanding social and medical forces that affect women’s health, including social roles,
economic status, access to health resources, experiences of health and illness, and interactions with
the health care system.
2
Charting a Course for the Future of Women’s and Perinatal Health
Therefore, the evolving women’s health field has begun to be shaped by a philosophy that
recognizes the impact of women’s multiple roles in society on health, that rejects a false dichotomy
between reproductive and non-reproductive health, and that focuses on women’s health assets
rather than just health problems. Accordingly, the Charting a Course initiative is guided by four main
perspectives:
❖
❖
❖
❖
A holistic perspective that considers the multiple influences of biological, psychological,
and social factors on women’s health and that embraces a wellness approach, rather than
being problem-focused. Such a perspective focuses on women’s assets, stressing their
resiliency and positive factors that affect their health.
A lifespan perspective that recognizes that women have different health and psychosocial
needs as they encounter transitions across their lives and that the positive and negative
effects of health and health behaviors are cumulative across a woman’s life. A lifespan perspective also means conceptualizing perinatal health within the context of women’s overall
health. Pregnancy is recognized as an important event in the life of a woman, although not
the only important event.
A social role perspective that recognizes that women routinely perform multiple, overlapping social roles.
A women-centered perspective that considers women’s gender-specific experiences as normative and recognizes the diversity among women in their health care needs and access to
adequate health resources.
The Evolution of the Field of Women’s Health†
As the field of women’s and perinatal health has evolved dramatically during this century,
public policy has followed suit. Historically, women’s health has been equated with reproductive
health and women’s capacity to bear and nurture children. Medicine in the second half of the 19th
century, influenced by prevailing theories of biological determinism and fundamental differences
between the sexes, operated under the presumption that female reproductive organs were not only
central to childbearing but also controlled women’s overall physical and mental health.1
Public policy in the late 19th and early 20th century reflected this focus on reproduction as
the defining aspect of being a woman. Legislation prohibiting contraception and abortion was justified as preserving women’s primary maternal role. Labor laws — such as setting maximum limits
on the number of hours women worked outside the home — protected women’s health for their
caretaking roles. During the Progressive Era, women’s organizations, social welfare workers, and
some segments of the health professions promoted maternal and child health programs — including maternal education, prenatal care, and child health clinics — as necessary social and medical
reforms. The creation of the Children’s Bureau in 1912 and the passage of the Sheppard-Towner
Maternity and Infancy Act of 1921 created the first federally subsidized programs for maternal and
infant health.2
Even the early proponents of legalized birth control argued that contraception was necessary to improve maternal health by giving married women the right to control their sexual and
reproductive lives.3 The leaders in the Children’s Bureau, however, did not support legalized birth
control at the time, foreshadowing what would become a continuing debate within the field about
focusing on either reproductive rights or maternal and child health.4 Nevertheless, both sides shared
the view that women’s health was primarily about reproduction.
†
This section adapted from Weisman CS, 1997. Changing definitions of women’s health: Implications for health care and
policy. Maternal and Child Health Journal, 1(3):179-189.
3
Charting a Course for the Future of Women’s and Perinatal Health
The American medical profession formalized the tie between reproduction and women’s
health in 1930 by creating a specialty board in obstetrics-gynecology, which was restricted to physicians who served only women, thereby excluding general practitioners from certification.5 After
World War II, the role of obstetrician-gynecologists in well-woman and preventative care expanded. By the 1960s, they had become the gatekeepers for women to medical contraception, legal abortion, and cervical cancer screening (Pap smears). As a consequence, women born after 1945 were
far more likely to receive care from obstetricians-gynecologists than any previous generation.
Title V of the Social Security Act of 1935 signaled a shift in public policy toward improving
access to pregnancy-related and other reproductive health services for poor and underserved
women. Many other federal programs over the ensuing 60 years have built upon this legacy, including the Emergency Maternity and Infant Care program (1943) for the wives and children of servicemen in World War II, the Medicaid program (1965), Title X family planning programs (1970),
the Special Supplemental Food Program for Women, Infants and Children (1972), and Medicaid
expansions for childbirth and family planning (1980s).6-8
In the 1960s and 1970s, the Women’s Health Movement challenged the male-dominated
medical profession’s control over women’s reproductive lives, leading to much-needed reforms.9
Only 7 percent of obstetricians-gynecologists and 7.7 percent of all allopathic physicians10 were
women at the time. Roe v. Wade led to the growth of non-hospital facilities to provide surgical abortions. Alternative forms of health care delivery for women were created, including feminist women’s
health centers and freestanding birthing centers. Hospitals began to change their childbirth practices, creating home-like labor and delivery suites and rooming-in services. The federal Food and
Drug Administration mandated that information inserts be included in packets of oral contraceptives. In addition, a strong women’s health advocacy community, including the Boston Women’s
Health Book Collective (publishers of Our Bodies, Ourselves) and the National Women’s Health
Network, disseminated health information and influenced federal and state health policy. As a result
of the movement and ensuing federal anti-discrimination laws, the number of women physicians
doubled between 1970 and 1980. By 1995, women accounted for 22 percent of all active physicians,
30 percent of obstetricians-gynecologists, and 34 percent of residents and fellows.11
Around 1990, another wave of women’s health activism emerged, focusing on broadening
the nation’s concept of women’s health.12 Led by women who had attained positions of influence
in government, health professions, academia, and the health care industry, this movement sought
equity for women in biomedical research and health care delivery and a new focus on women’s
health throughout the lifespan. A number of important health policy initiatives developed at the federal level. For example, federal funding for breast cancer research increased from $90 million in
1991 to $500 million in 1995. The Breast and Cervical Cancer Mortality Prevention Act of 1990
improved access to screening services for low-income, uninsured, and other underserved women.
The Women’s Health Initiative, the largest study ever funded by the National Institutes of Health
(NIH), was launched in 1993 to research the health of mid-life and older women. NIH and other
operating units of the U.S. Department of Health and Human Services created new offices to oversee and coordinate the women’s health agendas in their agencies.
The changes in the women’s health field and women’s health policy of the last 30 years reflect
an evolution from a biomedical, reproduction-oriented model of women’s health to one that is more
holistic, incorporating biological, psychological, and sociological influences over the whole lifespan
of women. As was described above, this new model of thinking informs the work of this initiative.
4
Charting a Course for the Future of Women’s and Perinatal Health
The Social Context of Women’s and Perinatal Health†
Familiarity with recent social and demographic trends that affect women is essential for
understanding the context of women’s and perinatal health in the United States. Social, economic,
and political forces help shape women’s health by influencing trends in population characteristics,
education and employment, reproduction and family composition, and household economic status.
In turn, these demographic trends, which are outlined briefly here, help shape the roles women
play in their families, the workforce, and society in general. For example, the population of women
in the United States will continue to age and become more ethnically diverse in the coming decades.
Women are participating in the labor force more than ever before, and they are more likely to delay
childbearing and marriage than in the past. The proportion of single-parent households headed by
women continues to rise. In addition, all of these demographic factors and trends contribute to
women’s predisposition for chronic disease, access to health care, and personal health beliefs and
behavior. Moreover, these factors are highly interrelated; for instance, limited educational achievement constrains job opportunities and earnings, which affect access to adequate health care.
While women as a group have achieved significant improvements in such areas as educational attainment and economic earnings in recent decades, substantial variation persists among
women of different races and cultural backgrounds. In addition, with the majority of women active
in the workforce, policymakers are just beginning to recognize the importance of women’s multiple roles in society — working for pay outside the home, performing unpaid work at home, and
serving as caregivers for dependent children and aging parents — and the effect this has on
women’s health. These realities have important implications for formulating social and health policy, designing health services, and developing research agendas.
Women in the United States are living longer, meaning the population is aging overall.
While about 44 percent of the 135.5 million women in the United States were 15-44 years in 1996,
the leading edge of the large Baby Boom generation is now in its early fifties.13-16 With their longer
life expectancy, women make up a greater proportion of the old and very old; in fact, among individuals 85 years and older, there are only 39 men for every 100 women.13 Life expectancy, however, varies by race and socioeconomic status, with minority and poor women lagging behind. The
aging of the population has important consequences for health resource allocation, particularly in
terms of treating chronic conditions.
The distribution of women by race and ethnicity is expected to shift dramatically over the
next several decades, led by high growth rates among Hispanics. Currently, Whites make up 75 percent of the population of U.S. women; by 2050, they will account for only 53 percent.10 Such demographic shifts are significant, since disease susceptibility and access to care vary among racial and
ethnic subgroups. For instance, death rates from heart disease, stroke, and cancer are higher among
Black women than most other groups, and Hispanic women are less likely to have health insurance
and to have seen a physician in the past year.17
The education gap between women and men is closing, yet disparities persist among
women of different races. The percentage of women with college educations has increased faster
than for men in recent decades. At the high-school completion level, 89 percent of young women
and 86 percent of young men had diplomas in 1997.18 However, among women, Whites (89.4 percent) and Blacks (87.1 percent) are more likely to complete high school than Hispanics (64.9 percent). Differences in college completion are more striking; among women aged 25-29, 30.7 percent
†
Material adapted from Minkovitz and Baldwin in Charting a Course for the Future, Volume II.
5
Charting a Course for the Future of Women’s and Perinatal Health
of White women, 16.4 percent of Black women, and 12.7 percent of Hispanic women held bachelor’s degrees in 1997.18 Educational achievement is generally highest among Asians and Pacific
Islanders. Continuing educational disparities among racial groups may contribute to restricted
employment opportunities and earning potential for Black and Hispanic women particularly, thereby affecting their health and that of their families.
The proportion of women in the labor force has increased dramatically since 1950, reaching 59 percent in 1994, yet knowledge about the impact of paid employment on women’s lives and
health is incomplete at best.19 The gender discrepancies in earnings from paid employment that persist (women’s median income is 74 percent of men’s) have been attributed, in part, to sex-segregation of jobs and interruptions in employment for childbearing and caregiving.20 Among women,
earnings vary according to race, education, and family type, with less educated, minority, and single, female-headed households at the greatest disadvantage.18,20 Increasingly, single and married
mothers with children are in the labor force. In 1996, 62 percent of mothers with preschool-aged
children had paid employment.21 And, in 64 percent of two-parent families with children under 18,
both the husband and wife work outside the home.22
Labor force participation is important to understanding women’s health for two main reasons. First, socioeconomic status is linked to health. Women with lower incomes are more likely to
be in fair or poor health, have limitations in activity, engage in high-risk behaviors, and experience
acute health conditions.13 Girls raised in poverty are more likely to be overweight and sedentary,
which is associated with chronic disease later in life. Second, the demands of employment outside
the home can affect women’s health directly through occupational hazards and stress and indirectly by making it more difficult for them to fulfill their caretaking and self-care responsibilities, particularly if they are single mothers with inadequate childcare, for example.
Women increasingly are likely to have children later in life. Since 1990, while the birth rate
among teens has declined, it has risen among older women.23,24 In fact, between 1970 and 1986, the
first birth rate among women aged 30-34 rose 140 percent. A growing proportion of women are
remaining voluntarily childless while the percentage of women who are involuntarily childless is
constant.25
Women also are delaying marriage. The median age at first marriage for women has
increased from 20.8 in 1970 to 24.5 in 1994.26 One of two marriages ends in divorce, and divorce
rates are highest among the young and the less educated.25,27 Women are also increasingly likely to
give birth outside of marriage. In 1996, 32.4 percent of births were to unmarried women, although
the proportion varies by race with Hispanic (40.9 percent) and Black (68.9 percent) women having
higher rates than White women (25.7 percent).27 This evidence that many women are choosing to
delay childbearing and to remain voluntarily childless highlights the need to adopt a more comprehensive approach to the health care needs of women. A limited focus on reproductive health
may fail to identify and meet the needs of women who do not enter the healthcare system for childbearing-related services.
As a result of these trends in childbearing, marriage, and divorce, the proportion of singleparent families led by women has increased substantially. In 1994, female-headed households
accounted for 18 percent of all families, compared with 11 percent in 1970. Among Black families,
fully 48 percent are headed by single women.28 Households headed by single women are at a severe
economic disadvantage. For example, in 1997, the median household income for female-headed
households was $23,040; for male-headed households, $36,634; and for married-couple households,
$51,681.29 And single mothers often receive little support from the fathers of their children. In 1991,
24 percent of the women due child support did not receive any payment. Of those women who did
receive support, 66 percent got only partial payment.30
6
Charting a Course for the Future of Women’s and Perinatal Health
These trends and the ways they interact have significant implications for women’s health
and caregiving roles. For instance, the risks associated with increased labor force participation —
encountering occupational hazards and juggling multiple roles — may be offset by increased financial independence and self-esteem. Such positive outcomes, however, depend upon a woman’s type
of job, her earnings, her social responsibilities and the social supports she receives, as well as the
cultural norms of her environment.
Women’s multiple roles as paid workers and caregivers have sparked controversy as society grapples with issues related to comparable worth, gender discrimination in the workforce, child
care, and the division of household labor among adults. Some research has found an association
between employment and good health as measured by self-esteem, perceived health, and physical
functioning.31-33 However, excessively demanding jobs and conflicting responsibilities are linked with
poor health — for instance, job strain can exacerbate chronic diseases like hypertension.34 Women’s
caretaking roles have changed significantly due to the decline of extended families, the reduced proportion of two-parent households in which men serve as primary wage-earners, and the growth of
single-parent households. In addition to contributing solely or substantially to their families’ incomes
by working outside the home, many women are also the primary caregivers for children and aging
parents.26,35,36 As with paid employment, extremes in caregiving are associated with poor physical
health.
Despite significant gains in narrowing the gaps in social indicators for men and women and
for women of different racial and ethnic backgrounds, discrepancies persist with regard to life
expectancy, educational attainment, employment, and earnings. Improving the social climate that
influences women’s health means addressing these fundamental differences. A clear understanding
of these differences and their implications should drive the design, implementation, and evaluation
of policies aimed at improving the health of women in the United States.
7
8
C
hapter II
Key Topics in Women’s and Perinatal Health:
Findings from the Literature
Introduction
A
s part of the process of developing recommendations for the field, the Charting the Course
initiative undertook a broad assessment of published research, policy reports, and program
reviews on women’s physical health, mental health, and health behaviors, and on the
effects of health services and systems on women’s and perinatal health. Faculty associated with the
Johns Hopkins University Women’s and Children’s Health Policy Center wrote a number of review
papers on topics ranging from smoking to pregnancy care, from domestic violence to chronic diseases (see Charting a Course for the Future of Women’s and Perinatal Health: Volume II — Reviews
of Key Issues). Multiple data sources informed the literature reviews, including peer-reviewed literature, U.S. government publications (such as census data), relevant textbooks on women’s health,
and other sources as appropriate. These publications are cited in the individual sections. When
available, recent data are provided for women of different ethnic and racial groups. However, the
availability of such data varies by topic, and not all studies and reports provide comparable information, nor do they all use the same categories and labels for race and ethnicity. Similarly, as the
initiative’s focus is on women from menarche to menopause, most data are limited to women in
this age group. However, data sources vary in their specific age delineations and these distinctions
are noted in the specific chapters.
Chapter II is divided into twelve sections, each representing a summary of a literature
review found in Volume II of this series. The summaries provide recent information on aspects of
women’s health. The first two focus on the health care system as a whole, describing the current
state of health care services for women and explaining the role of public health in promoting the
health and well-being of women. The next three concentrate on women’s reproductive health,
including diseases of reproductive organs, issues of pregnancy planning and unintended pregnancy, and the current state of pregnancy care. The remaining seven sections look at specific issues in
women’s health: chronic diseases, depression, domestic violence, nutrition, physical activity, drug
and alcohol use, and smoking.
9
Charting a Course for the Future of Women’s and Perinatal Health
The topics chosen for review are not meant to represent all of the important issues in
women’s health. Other health conditions and behaviors and aspects of the health care system
deserve study as well. Some of the health conditions reviewed were selected on the basis of their
prevalence among women. Others were chosen because they represent behaviors or conditions that
have effects on women’s health across the lifespan, that affect women of different socioeconomic
levels, and that can be influenced by health promotion interventions. Cross-cutting themes found in
the topical reviews are summarized at the end of this chapter. Major ideas for policy goals and recommendations related to each topic are incorporated in Chapter III, “Recommendations for the
Future of Women’s and Perinatal Health.”
The 12 literature summaries are:
❖
Health Care Services and Systems for Women of Reproductive Age
❖
Public Health Roles Promoting the Health and Well-Being of Women
❖
Women’s Reproductive Health and Their Overall Well-Being
❖
Pregnancy Planning and Unintended Pregnancy
❖
Issues in Pregnancy Care
❖
Women’s Experience of Chronic Diseases
❖
Depression in Women
❖
Abuse Against Women by Their Intimate Partners
❖
The Nutritional Status and Needs of Women of Reproductive Age
❖
Women’s Physical Activity in Leisure, Occupational, and Daily Living Activities
❖
Effects of Drug and Alcohol Use on Women’s and Perinatal Health
❖
Effects of Smoking on Women’s and Perinatal Health
Health Care Services and Systems for Women of Reproductive Age†
Recent attention to women’s health issues reveals that women’s care is based on insufficient
research and is fragmented in its delivery, particularly with regard to the separation of reproductive
and non-reproductive services. Women in the United States obtain health care services from a wide
variety of sources, and they frequently enter the health care delivery system for either pregnancy
prevention or pregnancy-related services. The array of health service organizations serving women
include both public and private entities, and some women may use a combination of both. Unless
a women is enrolled in a managed care plan of some type, her use of multiple sources of health
care is unlikely to be coordinated by any provider or payer. The current health care delivery system for women therefore results in both redundancies and gaps in services, with the potential for
discontinuities as women age and change providers or health insurance plans.
†
Material adapted from Weisman and Poole in Charting a Course for the Future, Volume II.
10
Charting a Course for the Future of Women’s and Perinatal Health
Because health care providers have not traditionally been trained in, or responsible for, all
aspects of women’s care, some women’s health problems have been neglected in both research and
clinical practice. These include eating disorders, domestic violence, sexual abuse, depression, sexual dysfunction, chemical dependency, the menopause transition, and gender-specific aspects of
such chronic conditions as heart disease and diabetes. Many women do not have access to the type
of “primary care” that is comprehensive, coordinated, and based on sustained partnerships between
provider and patient.1,2
Utilization Patterns
Women make greater use of the health care system than men, and their utilization patterns
are more complex. While constituting approximately one-half of the population, women made 60
percent of all visits to physicians and hospital outpatient departments in 1994. Sixty-one percent of
all hospital stays were made by women, excluding obstetrical stays.3,4
Eighty percent of women report having a usual source of care — predominantly physicians’
offices. Many women, however, obtain specialty reproductive health services or routine care in the
public sector, or from private organizations that rely heavily on public funds (e.g., Planned
Parenthood centers or school-based health centers). According to a 1993 survey, 33 percent of
women over the age of 18 use both an obstetrician-gynecologist and another primary care physician.4 The types of physicians women see influence the services they receive: women who do not
see obstetricians-gynecologists are more likely not to receive key preventive services according to
established guidelines.5,6 Visits to obstetricians-gynecologists account for about one-third of office
visits made by women ages 15 to 44.7 And while there are reported to be approximately 100,000
advanced practice nurses involved in providing primary care,8 less than 2 percent of women use
providers other than physicians as a regular source of care,6 and only 5 percent of all in-hospital
births are attended by certified nurse-midwives.9 Use of alternative providers is often constrained by
state regulations limiting prescribing practices, restrictions related to third-party reimbursement and
admitting privileges, and physician resistance.
Women of reproductive age use a diverse array of providers of health care, sometimes concurrently, and issues of comprehensiveness and continuity of care are critically important for this
age group. New types of women’s health centers are emerging that may help address both coordination and utilization concerns. These centers are hospital- or community-based. In 1993, there
were an estimated 3,600 women’s health centers nationwide, serving 14.5 million women.10 Twelve
percent of the centers provide comprehensive primary care. Many of these are models for innovative provision of primary care, but they have rarely been evaluated to determine their impact on
quality or costs.
Barriers to Women’s Health Care Access
Despite women’s greater overall use of care, they face a number of barriers to receipt of
care — both financial and non-financial. Financial barriers include the following, which relate to
lack of health insurance and inadequate insurance:
❖
Women are more frequently insured as dependents of spouses or other relatives.
❖
Women more often undertake part-time employment, where insurance benefits are limited.
❖
Women, particularly poor women, spend more out-of-pocket for health services.
❖
Although Medicaid is a key source of insurance for women, nearly one-third of poor and
near-poor women remain uninsured.11
❖
Low-income women’s Medicaid coverage primarily involves only pregnancy-related services.
❖
Recent welfare policy changes leave most immigrant women without health care coverage
and create new challenges in enrolling eligible women in Medicaid.12
11
Charting a Course for the Future of Women’s and Perinatal Health
❖
Access to public prenatal care programs and family planning clinics is threatened by limitations in government funding streams and by competition from managed care plans for
Medicaid clients, which also reduces the financial base of these organizations.13
Women face many non-financial barriers as well, including lack of availability of health services or appropriate service providers. For example, in 1989, one-quarter of U.S. counties had no
prenatal clinic services;14 in 1992, 84 percent of U.S. counties were without any providers of surgical abortions.15 Many women also must deal with limited availability of enabling services, such as
child care, transportation, and translation services.
Challenges and Opportunities Related to Managed Care
The growth of managed care implies both benefits and risks to women. Although the term
“managed care” is increasingly vague, its emphasis on cost control, coordination of services, and
preventive care has the potential to improve prevention and screening, provide more effective prenatal care, lower out-of-pocket costs, and foster better integration of reproductive and non-reproductive care for women. Managed care might result in fewer unnecessary interventions for women,
such as cesarean deliveries and hysterectomies. And because health maintenance organizations have
low copayments and do not have coinsurance or deductibles, out-of-pocket costs to women should
be lower and more predictable.16
However, potential risks associated with managed care include possible reduced access to
specialists, incentives to underserve, reduced time during visits for provider-patient communication,
and discontinuities in care associated with voluntary or involuntary plan switching. Also, some managed care plans serving Medicaid enrollees may be unprepared to address the special needs of lowincome women and their children, specifically chronic conditions, disabilities, mental illness, and
substance abuse, and also to provide linkages with needed social services.17
Quality Issues in Women’s Health Care
Currently there is no consensus on a definition of quality in women’s health. Two general
categories of issues are particularly relevant to quality: (1) increasing the knowledge base on the
effectiveness of specific services and (2) evaluating the effects of alternate health care delivery models (such as women’s health centers). Although attention has been devoted recently to outcomes
research that focuses on disease management, it is important to note that much of women’s health
care is not disease-related but is concerned instead with prevention and health maintenance.
Measures of quality currently being utilized under the Health Plan Employer Data and
Information Set (HEDIS) for commercially–insured women relate to: breast and cervical cancer
screening, early prenatal care, ongoing prenatal care, cesarean delivery and vaginal birth after
cesarean delivery (VBAC) rates, birth-related average length of stay, and postpartum checkups.
HEDIS measures monitored for women enrolled in Medicaid incorporate additional indicators related to pregnancy and childbirth and to linkages with social services. Additional measures of quality
in women’s health are under development within the National Committee for Quality Assurance.
Little is known regarding how women’s health care utilization and quality differ by provider
type and by organizational context. Research is needed to determine how receiving care from different types of primary care providers affects the quality of care; how the coordination of reproductive and non-reproductive care in different types of organizations impacts on outcomes; and
how the physician-patient communication process in different types of settings affects satisfaction
and other outcomes. Despite the massive changes underway in our health care system, little is
12
Charting a Course for the Future of Women’s and Perinatal Health
known about how new organizational forms, such as comprehensive primary care women’s health
centers and the various types of managed care organizations (including mental health and substance
abuse “carve outs”), are affecting women’s health care.
Public Health Roles Promoting the Health and Well-Being of Women†
Public health agencies nationwide implement core functions of assessment, policy development, and assurance, with the mission to “fulfill society’s interest in assuring conditions in which
people can be healthy.”1 Fundamental to improving the health of the population is public health’s
longstanding orientation to social equity issues, as well as its overarching perspective that addresses population health in the context of social, environmental, and behavioral factors. This perspective is significant, particularly given the need to consider the social and developmental aspects of
health unique to women.
Over the years, a number of health issue-specific initiatives and services have been developed, primarily through agencies of the U.S. Department of Health and Human Services, but also
within other cabinet agencies, such as Agriculture, Justice, and Labor. These activities pertain to all
levels of government: many are implemented at the state and community level under the auspices
of state and local public health departments, but frequently also via non-profit community agencies.
Such concentrated public efforts have been created primarily as categorical programs addressing a
broad range of concerns such as family planning, adolescent pregnancy prevention, smoking and
drug and alcohol abuse, sexually transmitted disease services, prenatal and perinatal care for women
and infants, nutrition, domestic violence prevention, and cancer prevention and early detection.
Public health programming in these areas has evolved to address population concerns that hospitals or office-based medical practice on their own could not.
Public health services, including surveillance of health status and needs, population-based
health education and promotion, screening, standards development and quality monitoring, as well as
gap-filling personal health services, are important to the overall system of health care for women over
the lifespan. Drawing on the U.S. Public Health Service’s “Ten Essential Public Health Services,”
Grason and Guyer have developed a framework specific to maternal and child health.2,3 The table
below provides examples illustrating the operationalization of the 10 essential services for three selected health issues specific to women — perinatal care, breast and cervical cancer, and partner violence.
†
Material adapted from Grason, Poole, and Silver in Charting a Course for the Future, Volume II.
13
Charting a Course for the Future of Women’s and Perinatal Health
EXAMPLES OF PUBLIC HEALTH FUNCTIONS AND ACTIVITIES RELATED TO
THREE SPECIFIC WOMEN’S HEALTH CONCERNS
Public Health
Function/Activity
Perinatal
Care
Cervical &
Breast Cancer
Partner
Violence
Assess & Monitor
Health Status
Use vital statistics data to study
birthweight-specific infant mortality and to monitor rates of
maternal mortality.
Enhance state and local utilization of data from the national
breast and cervical cancer surveillance system to monitor incidence, stage at diagnosis.
Initiate a national survey of family
and intimate violence to address
the lack of systematic tracking of
violence against women (e.g.,
Centers for Disease Control and
Prevention-National Institute of
Justice survey).
Diagnose &
Investigate Health
Problems &
Hazards
Extend and maintain existing initiatives, such as the Pregnancy
Risk Assessment and Monitoring
System, study of the rise in congenital syphillis from unidentified and/or untreated maternal
syphillis, and Maternal Mortality
Reviews, which uncover womanspecific and system factors contributing to poor pregnancy outcomes.
Conduct epidemiologic reviews
of high incidence areas and populations.
Investigate “clusters” of cases to
understand the risk factors for
violence, including violence
against women in the workplace
and violence against pregnant
women.
Inform & Educate
the Public
Provide resources and technical
expertise for the implementation
of national and local public
information campaigns on the
importance of early and continuous prenatal care.
Produce and disseminate culturally-appropriate information in
community agencies (e.g.,
senior centers, YWCAs) to
improve risk awareness and
encourage women to seek
screening consistent with recommended guidelines.
Fund community organizations,
such as domestic violence centers, shelters, and schools, to
institute collaborative youth violence prevention education programs.
Mobilize
Partnerships
Support community/grassroots
consortia, such as Healthy
Mothers, Healthy Babies
Coalitions, which prompt local
and state action on problems
of infant mortality.
Maintain national and local partnerships among the Centers for
Disease Control and Prevention,
American Cancer Society, YWCA,
National Associ-ation of Breast
Cancer Organizations, and
National Cancer Institute.
Develop partnerships with grassroots organizations, educators,
employers, and health care
providers for educating local and
state legislators about the problem of partner violence and
promising interventions designed
to address it.
Leadership for
Planning and
Policy
Development
Convene and support statewide
commissions focused on perinatal health to heighten public and
professional attention and to
guide policy development and
resource allocation based on
scientific evidence.
Designate resources and program authority to assure implementation of the National
Strategic Plan for the Early
Detection and Control of Breast
and Cervical Cancers.
Incorporate data and analysis
related to rape and battering
into required state MCH program needs assessments and
annual planning.
14
Charting a Course for the Future of Women’s and Perinatal Health
Public Health
Function/Activity
Perinatal
Care
Cervical &
Breast Cancer
Partner
Violence
Promote and
Enforce
Protections, and
Ensure Public
Accountability
Work with professional and hospital organizations to develop
standards and designate units
for risk-appropriate deliveries.
Establish medical advisory committees and dedicate state health
agency resources to monitor
mammography and cytological
services consistent with the
Clinical Laboratory Improvement
Act of 1988 (CLIA) and
American College of Radiology
Standards.
Work with police departments to
monitor implementation of legislation outlining legal penalties
for and restrictions on handgun
purchases by perpetrators of
domestic violence against
women.
Ensure Access to
and Linkages
Among Services
Provide prenatal care services
for immigrant and other women
without access to health care.
Allocate resources for free posttrauma medical examinations
for women who are victims of
violence by intimate partners.
Develop or maintain a regionalized system of perinatal services.
Establish systems under the
National Breast and Cervical
Cancer Early Detection Program
to provide care efficiently from
screening to diagnosis and follow up care.
Assure the Capacity
and Competency of
the Public and
Personal Health
Work Force
Promote practice parameters
and credentialing policies to
expand and enhance use of
advanced nurse practitioners
and nurse-midwives.
Develop educational curricula
for primary care physicians and
other health care providers, as
well as training materials and
reminder systems.
Support training for prosecutors, police, and service
providers in screening for partner violence in health care and
judicial encounters.
Evaluate Personal
and Public Health
Services
Provide technical expertise to
entities such as NCQA, JCAHO,
and FAACT in the development of
indicators/benchmarks
for
monitoring the delivery and
quality of services provided to
pregnant women and their newborns.
Identify barriers and factors
facilitating the use of health services.
Examine the effectiveness of primary care providers practicing
in managed care organizations
in identifying and treating
domestic violence against
women (e.g., studies from the
Agency for Health Care Policy
and Research).
Support Research
and
Demonstrations
Allocate discretionary resources for the development and
testing of model approaches
addressing urgent perinatal concerns such as substance abuse
among pregnant women (e.g.,
Maternal and Child Health
Bureau–Substance Abuse and
Mental
Health
Services
Administration Pregnant and
Postpartum Women and Their
Infants Program).
Fund clinical trials to determine
treatment outcomes.
Convene expert panels, such as
the Institute of Medicine Panel
on Research on Violence Against
Women, to analyze scientific evidence and make recommendations for improved policies and
strategies for addressing partner
violence.
15
Charting a Course for the Future of Women’s and Perinatal Health
Policy Challenges and Opportunities
Notwithstanding the increasing and important attention to women’s health within legislative
bodies and governmental agencies nationally and at the state and local levels, a number of key
issues demand attention and study as we approach the next century: coordinating governmental
leadership and initiatives; appropriating the necessary funding to ensure public accountability for
health systems development and monitoring as well as population-based prevention activities; and
sorting out public and private sector roles with respect to population health and prevention. All warrant careful consideration as women’s health issues become increasingly important in the public policy agenda.
Stable and Rational Funding Base for Public Health Functions and Services. Over recent years, public policy debates related to health have focused almost exclusively on insurance strategies for
improving health status. Legislation proposed and/or enacted both before and following the failed
national health care reform initiative has entailed insurance reforms addressing access, parity, and
portability concerns.
Further, for many years, public health agencies have been able to support population-based
prevention services and other public health functions (e.g., data/surveillance) with funds received
from reimbursements for direct health care provided to publicly-insured and other underserved
groups, such as Medicaid beneficiaries. However, as the publicly insured are increasingly being
channeled into cost-managed private sector care, resources for public health activities have begun
to dwindle. While it might be reasonable to assume that some managed care organizations (MCOs)
— especially the larger ones — may be able to provide selected population-based services, the issue
of public health funding is a critical issue both in the present and future. Will policymakers attempt
a balance so that assessment, surveillance, policy structures, independent quality monitoring, and
research and capacity building are maintained?
Accountability Related to Prevention Services in the Managed Care Environment. Increasingly, the
U.S. population is receiving health services through some variety of managed care entity.
Responsibility for clinical preventive services, such as breast and cervical cancer screening, has been
clearly delineated for health plans through practice guidelines, regulation, and purchaser contracting mechanisms. MCOs nationally have embraced accountability for these services through incorporation of measures of prevention services in their Health Plan Employer Data and Information Set
(HEDIS) performance reporting. Moreover, most insurance purchasers and health plan administrators acknowledge the individual and societal advantages of primary prevention, such as health education and wellness programming. To date, however, financial incentives for promoting health plan
accountability for such services have yet to be refined. Health education can be expensive. Costs
for primary prevention services are difficult to capture, and, as a result, are not often included in
capitated payments made to plans. Given managed care’s strategic goal to reduce costs and bolster
stockholder investments, alongside the protracted timeframe for realizing cost savings generated
from prevention, commitment to these functions in the private sector is not yet clear.
Further complicating the question of relying on health plans to undertake responsibility for
health education and promotion are issues surrounding the inadequacy and instability of insurance
coverage and the uneven distribution of health providers. As women move into and out of plans’
enrollee populations (often with change of employer or residence), savings might not accrue to a
plan that has made the investments in prevention. Absent universal health insurance for the resident population, funding and organizational accountability for primary prevention cannot effectively rest exclusively in the private sector. Moreover, if both public and private sectors are to share in
this responsibility, the question remains of how prevention and other population-based health services should or can be coordinated at the individual and community system levels.
16
Charting a Course for the Future of Women’s and Perinatal Health
Quality Assurance and Improvement at the Population Level. Measurement of quality at the community/state level represents an important set of functions traditionally assigned to public health. In
order to ensure that populations achieve national standards of health status (e.g., Healthy People
2000 Objectives), specific activities are needed for assessing population health in geographic areas
where multiple health care plans and provider networks deliver care and where some individuals
remain uninsured and/or underserved. At the same time that public health expertise and leadership
are increasingly important in addressing environmental and social issues (primary prevention) and
monitoring patterns of women’s health care coverage and utilization, public health’s access to relevant data is diminished as a consequence of market-driven, private sector health services organization. Marketplace competition is prompting health plans to limit sharing of encounter and other
important data and is promoting an emphasis on internal/peer quality monitoring strategies to the
exclusion of objective external assessment by public health entities. Ensuring population health for
women over future years will involve protecting the ability of public health agencies to fully utilize
their tools of the trade — epidemiologic, demographic, and statistical analysis of health data.
National Leadership for All Aspects of Women’s Health. As women’s health issues have gained prominence, federal agencies have sought to demonstrate their commitment to action by establishing over
a dozen organizational units specifically focused on women’s health. The U.S. Department of Health
and Human Services (DHHS), in particular, has dramatically increased attention to women’s health
concerns in recent years. As welcome as this organizational attention may be, proliferation creates
new challenges for coordination and integration of efforts. In 1999, many federal programming
efforts remain categorically focused, targeted on specific diseases/conditions (e.g., substance abuse,
breast and cervical cancers, family planning) or on specific functions (e.g., research, surveillance,
primary care services). Under the leadership of the U.S. Public Health Service’s Office on Women’s
Health, representatives of the various DHHS women’s health offices convene regularly to address
topics that span the programs within which they operate — such as the effect of managed care on
women’s health or training of women’s health professionals. Over time, it will be important that
DHHS seize all available opportunities to create an overarching national policy agenda and maintain a locus of accountability for women’s health within the federal government.
A second prominent challenge accompanying new attention to women’s health involves the
question of the convergence of policies, programs, and organizational entities having longstanding
leadership roles and statutory mandates with respect to women’s reproductive health with those
newly emerging. As Weisman (1998) notes, the field of maternal and child health, with roots established in the progressive movement of the early twentieth century, and the women’s health movement that emerged in the 1960s have most often pursued independent avenues for their work and
different constituencies for their growth.4 Key constituent groups promoting women’s health themselves are diverse in their focus and interact infrequently with organizations that traditionally provide advocacy related to maternal and child health. As noted above, until recently, administrative
units within the federal government addressed these issues independently.
The question of whether maternal and child health should be distinguished from women’s
health, and if so how so, demands and is receiving increased consideration in public health policy
deliberations. While the potential for synergy in the integration of the two is clear, the difference in
professional cultures, policy interests, and relative emphasis on women’s roles and rights vis-à-vis
those of their children (particularly in policy deliberations related to substance abuse, welfare
reform, and domestic violence) must be addressed as the fields evolve. In this current environment
of heightened attention and activity, the DHHS is well-placed to bring together the broad array of
constituency groups concerned with women’s health, maternal health, and child welfare to consider organizational structures and roles (among government and constituent coalitions) that can
strengthen all efforts on behalf of women and families.
17
Charting a Course for the Future of Women’s and Perinatal Health
Women’s Reproductive Health and Their Overall Well-Being†
Although reproductive health is no longer considered to represent the entirety of women’s
health care needs, it remains an important factor in women’s overall health. A woman’s reproductive health status influences her physical, psychological, and social well-being. This brief review
examines three specific reproductive health issues — infections, breast and cervical cancer, and
cesarean delivery — to highlight the predominant cross-cutting themes.
Epidemiological Trends/Demographics
Infections
❖
Two-thirds of all cases of sexually transmitted infections occur in persons under the age of 25.7
❖
Rates of syphilis in the U.S. have decreased since 1990, but remain significantly higher than
rates in other countries. The incidence of chlamydia and other sexually transmitted diseases
remains high.8
❖
Sexually transmitted diseases can lead to systemic infections, infertility, and ectopic pregnancy.
INFECTIONS AND RELATED CONDITIONS IN WOMEN
CONDITION
YEAR
RATE
Chlamydia1
1996
321.5 per 100,000
Gonorrhea1
1996
119.5 per 100,000*
Syphilis (1° and 2°)1
1996
4.0 per 100,000
Genital Herpes2
1997
25.6% infected with HSV-2
HIV (not AIDS)3
June 1996-July 1997
3,750 (new cases)
Human Papillomavirus4
1997 study
(n=376)
46% of college
students
Bacterial Vaginosis5
1995 cohort study
(n=10,000)
16% of
pregnant women**
Pelvic Inflammatory
Disease6
1994
177 hospitalizations
per 100,000 women
(15-44 years of age)
* Decreased 14.8% from 1995
** Ranging from 9-28%
†
Material adapted from Misra, Cassady, Rothert, and Poole in Charting a Course for the Future, Volume II.
18
Charting a Course for the Future of Women’s and Perinatal Health
Cervical Cancer
❖
❖
Of
the
14,500
women diagnosed
with cervical cancer
in 1997, 4,800 were
expected to die.10
Mortality is twice as
high
for
Black
women as White
women.10
INCIDENCE OF INVASIVE CERVICAL CANCER
PER 100,000 WOMEN, AGE-ADJUSTED
(SELECTED YEARS)9
YEAR OF
DIAGNOSIS
ALL
FEMALES
WHITE
FEMALES
BLACK
FEMALES
1975
12.4
11.1
28.0
1979
10.6
9.2
23.5
1983
8.8
8.1
15.2
1987
8.3
7.4
15.2
1991
8.4
7.7
13.4
1995
7.4
6.5
11.4
Breast Cancer
INCIDENCE OF FEMALE BREAST CANCER
PER 100,000 WOMEN (AGE-ADJUSTED)9
YEAR OF
DIAGNOSIS
ALL
FEMALES
WHITE
FEMALES
BLACK
FEMALES
1975
88.1
90.0
78.5
1979
85.5
87.5
72.5
1983
93.3
96.2
86.3
1991
112.1
116.4
98.1
1995
111.3
115.0
101.3
❖
Breast cancer is rare
but more fatal in
premenopausal
women.11
❖
180,200 new breast
cancer cases were
diagnosed in 1997,
and 43,000 deaths
were documented.12
❖
The prevalence of
breast cancer is leveling off at 110
cases per 100,000
women.13
19
Charting a Course for the Future of Women’s and Perinatal Health
Cesarean Deliveries
❖ Cesarean deliveries increased five-fold since 1970.14
There have been encouraging decreases, however, in
the rate in the 1990s.15
❖ Cesarean delivery is more costly than vaginal delivery
both in terms of dollars and its effects for the mother.16 The increased recovery time required may complicate family life by delaying a woman’s return to
child care and work responsibilities. Controversy has
recently re-emerged, however, about the level of
reduction of cesarean delivery rates that can be sought
without compromising quality of care.17
Risk Factors/Predictors for Disease
RATE OF CESAREAN DELIVERIES
PER 100 DELIVERIES,
UNITED STATES14
YEAR
CESAREAN RATE
1989
1990
1991
1992
1993
1994
1995
1996
22.8
22.7
22.6
22.3
21.8
21.2
20.8
20.7
Each reproductive health problem has multiple risk factors, many of which cross over to
other diseases. Risk factors for infections include multiple sexual partners (or a partner with multiple sexual partners), early age at first intercourse, failure to regularly use condoms, and drug abuse.7
Additionally, women with gonorrhea or syphilis are more likely to become infected with HIV.7 For
cervical cancer, infection with sexually transmitted human papillomavirus18-23 and smoking24-26 are risk
factors. Regarding breast cancer, risk factors include nulliparity, first birth after age 30,20,27,28 obesity,
weight gain,29,30 and low levels of physical activity.31-33 Cesarean deliveries are more likely with older
maternal age,34 high parity, small stature, high body mass index or high weight gain,35,36 obstetrician
provider compared to nurse-midwife,37-40 higher level of insurance reimbursement relative to vaginal
delivery,41 and prior cesarean delivery.42
Interventions
Overall, reproductive disease rates could be reduced by increasing healthy and reducing
risky behaviors among women — for example, for infections, condom use. For some diseases,
however, risk-reducing behaviors are harder to identify — for example, the nature and extent of
modifiable risk factors for breast cancer (rather than immutable risk factors such as age at menarche and genetic mutations) remain unclear.
Awareness by women, their families, and their providers of a number of sexually transmitted conditions is limited. To address this knowledge gap, the Institute of Medicine (1997) recommends an independent, long-term, national campaign to promote a new norm of healthy sexual
behavior in the United States. This norm would promote open discussion of healthy sexual behaviors, including using condoms and other means of protection against sexually transmitted diseases
(STDs) and unintended pregnancy, and delaying the age of first intercourse.7 Infections also can be
prevented by behavioral interventions based on social learning theory and social marketing (in the
mass media).43,44
Women need improved access to health care providers and services. Screening (and treatment) services provided in local health department STD clinics, publicly funded community-based
health clinics, and private health care settings serve different but sometimes overlapping population groups, and each group has somewhat different needs. Moreover, women are under-represented among those served in public health STD clinics and over-represented in the group served
20
Charting a Course for the Future of Women’s and Perinatal Health
by community-based agencies (which include family planning clinics).7 Women are more likely than
men to be asymptomatic from sexually transmitted diseases, and thus are potentially less likely to
seek out screening or treatment and more likely to experience adverse sequelae.7 Early detection
and effective treatment reduce the duration of infection, thus decreasing the likelihood of transmission to others. In addition, partner notification and insurance coverage of partner treatment are
both currently inadequate and uncoordinated. The knowledge base related to infections that are not
sexually transmitted—such as bacterial vaginosis and group B streptococcus disease—needs to be
expanded in order to identify those factors influencing risk of acquiring these infections.
Pap screening can detect cervical cancer early, and breast self-examination can increase
early detection of breast cancer. Unfortunately, data from health plans indicate that there is great
variation in mammography and screening rates among health plans. Rates of screening for breast
cancer range from 27.7 percent to 89 percent, and from 24 percent to 100 percent for cervical cancer screening.45 These rates are modifiable, indicating an area of opportunity for improvement.
Some persistent barriers to adequate reproductive health are technological. Methods to stem
transmission of infections, particularly female-controlled methods (e.g., topical microbicides and
vaccines), are limited. Less expensive, less invasive (e.g., urine- or saliva-based), and more rapid
tests need to be developed for screening and diagnosing reproductive tract infections. Moreover,
technology related to screening for breast cancer in younger women is underdeveloped.
More epidemiologic information about relatively “benign” gynecologic health conditions
(e.g., dysmenorrhea, endometriosis, and uterine fibroids) is needed; while these conditions are not
fatal, they impact on women’s quality of life.
Finally, insurance coverage (public and private) for comprehensive reproductive health services, which include screening and treatment for sexually transmitted diseases and breast and cervical cancer, remains limited.
Pregnancy Planning and Unintended Pregnancy†
The rate of unintended pregnancies in the United States is higher than that of many other
industrialized countries, with 57 percent of all pregnancies and 44 percent of all births unintended.1
Over the past several decades, sexual activity among teens and births to unmarried women have
increased, age of first sexual activity has steadily decreased, and marriage has been increasingly
delayed,2 all contributing to the high rates of mistimed and unwanted pregnancies. Although the
rates of mistimed births remained constant through the 1980s, the rate of unwanted births increased.3
Three-quarters of women have had intercourse by age 19, and among adolescents intercourse is rarely planned.4 Only 40 percent of young women go to a doctor or clinic for contraceptive
services within the year of their first intercourse.5 Nevertheless, in the first half of the 1990s, teen birth
rates fell in all 50 states, dropping by at least 5 to 10 percent in 37 states. The largest declines were
reported among African-Americans.6 Repeat childbearing among teenagers also has shown dramatic
declines since 1991.7 Still, over 10 percent of all births each year are to women aged 15-19,8 and teen
birth rates remain far higher among African-Americans (91.7 per 1,000), Hispanics of any race (101.6),
and Native Americans (75.1) than among Whites (48.4) and Asians or Pacific Islanders (25.4).9
†
Material adapted from Poole and Hawkins in Charting a Course for the Future, Volume II.
21
Charting a Course for the Future of Women’s and Perinatal Health
Predictors and Consequences of Unintended Pregnancy
A disproportionate number of women who have unintended pregnancies are at the lower
or upper ends of the reproductive age span.1 Among ever-married women, the prevalence of
unwanted births increases with age and parity, most likely because these women have already
reached their desired family size.
The consequences of unplanned pregnancies may include inadequate prenatal care,1,10-13
greater numbers of abortions, and poor birth outcomes, although the data on this point are mixed.1,14
There is some evidence that the apparent link between adverse outcomes, such as low birthweight,
and unplanned pregnancy is actually due to confounding maternal and paternal factors (e.g., age,
employment status, and parity).15,16 Unplanned pregnancies also incur higher medical costs. The estimated annual medical costs of unintended pregnancies reach $13 billion.17
Unintended pregnancy in adolescence has been linked to inadequate prenatal care, low
birthweight, infant mortality, child abuse and neglect, and lower educational and economic status
for both mother and child.18 Nearly one-half of mothers receiving Aid to Families with Dependent
Children were less than 17 years of age when they had their first child.19 About one-quarter of
teenage mothers have a second child within 24 months of their first birth,20 and the prevalence of
closely spaced second births is greatest (31 percent) among women whose first birth occurred prior
to age 17.21 African-American women are 1.6 times as likely as White women to have an interval of
less than 18 months between deliveries.20 Several investigators have proposed a link between intervals of less than six months between pregnancies and poor pregnancy outcomes, including low
birthweight, intrauterine growth retardation, preterm delivery, and perinatal mortality.22-25
Interventions and Health Care Utilization
Contraception. Nearly one-half of unintended pregnancies occur to women who report having used
reversible contraception at the time of conception.1 The remaining unintended pregnancies occur
among women not using contraception. Several factors may complicate a woman’s decision about
the use of available contraceptive methods, including parity, lactation, and desire to be protected
against sexually transmitted diseases (STDs).26 For younger women, embarrassment, concerns about
privacy, and lack of access to medical services may present serious barriers.5
Despite a relatively high failure rate in typical use, most birth control methods approach 100
percent efficacy when used correctly and consistently. The combined first-year failure rate for all
methods except sterilization was 14 percent in 1988.27 Due to inconsistent or incorrect use, non-use,
or failure of contraceptive methods, 3 million women unintentionally become pregnant each year.5
Contraceptive failure of condoms accounts for 32 percent of unintended pregnancies
among women seeking abortion services.28 Condom use more than doubled in the 1980s, probably
due to concerns about HIV transmission.27 While condoms are highly effective in preventing transmission of STDs, their high contraceptive failure rate is of concern. The oral contraceptive pill is the
most popular of all reversible contraceptive methods, although it does not protect against STDs.
Emergency contraceptive treatment (morning after pills) has been slow to enter the U.S.
market. This is a consequence of past reluctance on the part of manufacturers to apply to the U.S.
Food and Drug Administration for approval of their oral contraceptives as emergency contraception
products — and reluctance on the part of physicians to prescribe them — due to concerns about
legal liability.29 Despite the fact that oral contraceptives have been packaged and labeled for emergency contraceptive use in European countries for some time, the first emergency contraception
product, the “Preven Emergency Contraceptive Kit,” did not gain FDA approval until the fall of 1998.30
22
Charting a Course for the Future of Women’s and Perinatal Health
The cost of contraceptive drugs and devices and related physician fees may deter significant numbers of women,31 particularly if insurance coverage of contraceptive services is minimal;
only 33 percent of traditional indemnity plans cover oral contraceptives.32 However, federal legislation recently enacted now requires insurance plans participating in the Federal Employees Benefit
Plan to cover contraceptive drugs.
Abortion. Of the six million pregnancies that occur in the United States annually, 1.6 million end in
abortion.33 Women seeking abortion are more likely than women in the general population to be
White, Hispanic, between the ages of 19 and 24, separated or never-married, enrolled in Medicaid,
and earning less than $15,000 annually.28
Public funding of abortion is supported almost entirely by the states; federal Medicaid dollars cover abortions only in the event that the woman’s life is threatened or the pregnancy is the
result of rape or incest. Only 13 states and the District of Columbia provide funds for abortion for
Medicaid recipients, and only four states and the District of Columbia fund abortions without restrictions on the reason for the procedure.34
Women seeking abortions face numerous barriers:
❖
Prohibitions on public funding of abortions restrict the ability of poor women to end
unwanted pregnancies.34
❖
In 1993, almost one in ten women seeking an abortion outside a hospital had to travel over
100 miles.35
❖
Harassment of abortion providers and patients has reduced access to abortion services.35
❖
Most abortions are paid for out-of-pocket because women seek confidentiality or do not
have insurance that covers the procedure.35 However, the average cost of an abortion at a
non-hospital facility ranges from $600 to over $1,000 depending on gestational age. Cost is
thus the major barrier for many women seeking abortion.
Pregnancy Planning Services
Provider roles in counseling. Health care providers are in a unique position to counsel women about
pregnancy planning. Results of studies on counseling among physicians are mixed. Providers of
obstetric and gynecologic services initiate discussions about birth control and sexual activity with
only about one-third of new patients, and about STDs with only 12 percent.36 Family practice and
pediatric physicians more regularly counsel patients about preventing pregnancy and STDs, but
often feel they are not effective in their counseling.37,38 On the other hand, physicians report a high
level of counseling for adolescent patients, with 97 percent of pediatricians in one study counseling teenage patients about STDs and 62 percent nearly always taking a sexual history.37
Much of women’s primary care is delivered by non-physician providers.39 Primary care
delivered by non-physicians seems to be equal in quality to that provided by physicians, and nonphysician providers may actually do a better job of preventive care and communicating with
patients.40 The gender of the provider may also be important, with female physicians spending more
time both listening to and educating patients than do their male counterparts.41
Deficiencies in physician training may account in part for inadequacies in women’s reproductive health care.42 Curricula specific to women’s health for medical students and for residents in
family practice, internal medicine, obstetrics and gynecology, and psychiatry are offered in a minority of medical schools.39
23
Charting a Course for the Future of Women’s and Perinatal Health
Integration of reproductive health services. Improved integration of different types of reproductive
health services would likely aid prevention efforts.43,44 Although many providers already do offer
integrated services (both family planning and STD services, for example), federal categorical funding streams create administrative burdens.44,45
Public pregnancy planning programming. Title X of the Public Health Service Act has funded the
provision of family planning services, as well as related research and training, since its creation in
1970. However, due to only modest federal funding of Title X and expansions in Medicaid eligibility throughout the 1980s and 1990s, Medicaid is currently the primary federal financing mechanism
for family planning services.34 State Title V Maternal and Child Health Programs and state-appropriated dollars also support public family planning services in a number of states.
By the end of 1997, a total of nine states had waivers approved by the Health Care
Financing Administration to expand access to Medicaid family planning services. These 1115 waivers
allow states to make family planning services more widely accessible with the objective of addressing the issue of short interpregnancy periods, which tend to occur more frequently in low-income
minority women. Without this waiver approach, Medicaid eligibility for many low-income women
is tied to pregnancy status.
Prior to the federal welfare reform legislation in 1996, states were required to fund family
planning services for welfare recipients. Although that mandate no longer exists and, in general,
states are barred from using Temporary Assistance for Needy Families (TANF) funds for medical services, states are permitted to use TANF funds for prepregnancy family planning services.46
Our knowledge base needs to be bolstered in order for more effective family planning
methods to be developed for men and women. Tradeoffs between effectiveness in preventing pregnancy and preventing STDs highlight the need for development of contraceptive methods that effectively serve both needs. Similarly, assessment of policies allowing for over-the-counter purchase of
oral contraceptives is needed to weigh the benefits of reducing unintended pregnancy rates against
disincentives for regular gynecological check-ups. Factors related to the effectiveness of emergency
contraception need to be examined. Qualitative studies should be pursued to understand the best
ways to educate women and providers about this method.
Issues in Pregnancy Care†
Pregnancy is a critical event in the life of a woman that shapes her relationships with her
partner and family, her role in the workforce, and also affects her health. Close to four million births
occur annually in the United States, along with an estimated 60 percent or more additional pregnancies to women that end in spontaneous losses, stillbirths, or induced abortions.1 Over ninety percent of women aged 15-44 responding in the 1995 National Survey of Family Growth reported
expecting to give birth at least once during their lifetime.2
Indicators of Maternal Morbidity and Mortality
Increasingly, attention has been given to measuring morbidity and mortality related to pregnancy and improving the reporting of these incidents. Frequently reported maternal medical complications during pregnancy are pregnancy-induced hypertension (3.6 percent of women), diabetes
(2.6 percent), anemia (2.0 percent), and chronic hypertension (0.7 percent).3 The completeness of
†
Material adapted from Strobino, Nicholson, Misra, Hawkins and Cassady in Charting a Course for the Future, Volume II.
24
Charting a Course for the Future of Women’s and Perinatal Health
reporting of maternal medical complications has improved since the introduction in 1989 of a checklist of 16 complications of pregnancy on the standard recommended birth certificate. The prevalence, however, is still underreported.4
Antenatal Hospitalization and Bed Rest. Antenatal hospitalization and bed rest are proxy measures
of the morbidity of women during pregnancy. Each year, between 12 and 27 percent of all deliveries in the United States are preceded by an antenatal hospitalization.5-8 History of medical or obstetric problems and lack of prenatal care are associated with antenatal hospitalization.6,9 The most common immediate cause is preterm labor, followed by hypertension, diabetes, bleeding/placenta previa, and premature rupture of the membranes.6,7 Studies examining a possible racial disparity in risk
of antenatal hospitalization show conflicting results.5,6,8,9
Bed rest is prescribed in close to 20 percent of all U.S. pregnancies10 and is recommended
prophylactically to reduce the risk of several adverse conditions and pregnancy outcomes, including spontaneous abortion, preterm labor, fetal growth retardation, edema, chronic hypertension, and
preeclampsia.11-13 Although bed rest is widely recommended, it can have significant detrimental
effects on women, including lost wages, disruptions in daily living, and increased levels of stress.14
Maternal Mortality. Maternal mortality is considered a benchmark of the health of a community.15
The magnitude of maternal mortality is in question, however, based on the manner in which data
are compiled from vital statistics. It is estimated that the number of pregnancy-related deaths is 1.3
to 3 times greater than that reported in vital statistics data.16 The pregnancy-related mortality ratio
increased from 7.2 in 1987 to 10 in 1990, and the rate of increase was greatest for Black women.17
Racial disparities exist for every cause of maternal mortality, including hemorrhage, embolism,
hypertensive disorders, infection, cardiomyopathy, and anesthesia.18 Risk of maternal mortality is
also higher for unmarried women, women with low levels of education, women with inadequate
prenatal care, and women with higher order multiple pregnancies.18
Methods for surveillance of maternal mortality and morbidity must improve in order to
develop effective interventions, identify high-risk groups, and monitor trends. Efforts to improve the
quality of the data must be coupled with a commitment to educate obstetricians, nurse-midwives
and family practice doctors about the need to improve the reporting of complications on vital records.
Low Birthweight and Preterm Delivery. The health care needs of the newborn also offer insight into
maternal health and the quality of care during pregnancy. Low birthweight (LBW) infants account
for over 7 percent of all U.S. births.3 This percentage has increased in recent years for White women,
but has dropped for Black women. The change in LBW among White women is believed to be related to increases in the number of women with multiple pregnancies, which is more common among
women who receive treatment for infertility or who delay childbearing.3
LBW has a multi-factorial etiology, associated with:
❖
medical risk factors, such as nulliparity and parity greater than 4, chronic diseases, previous LBW infant, genetic factors, multiple pregnancy, poor weight gain, infection, placental
problems, premature rupture of membranes, and fetal anomalies;
❖
demographic risk markers, such as age less than 17 and over 34, African-American race, low
socioeconomic status, unmarried status, and low level of education; and
❖
behavioral risk factors, such as smoking, poor nutrition, toxic exposures, unintended pregnancy, inadequate prenatal care, illicit substance use, and stress.19
The primary cause of LBW is preterm birth, which occurs in 11 percent of deliveries.3
Because the etiology of preterm delivery is largely unknown,20 progress in reducing the rate of early
births has been slow. Preterm infants are at increased risk for infant mortality; nearly 70 percent of
25
Charting a Course for the Future of Women’s and Perinatal Health
all neonatal deaths can be attributed to preterm birth. Preterm infants (especially very preterm
infants) who survive are at increased risk for developmental delays and a variety of chronic conditions.21,22 Research on the etiology of preterm labor must address the social as well as biological
determinants of preterm birth, with special emphasis on modifiable risk factors. Moreover, future
research needs to address the many potential reasons, both social and medical, for continued racial
differences in preterm births.
Preconception and Pregnancy Care Services
Preconception care, which emphasizes the need to view women’s health as a continuum,
has been promoted as one strategy to assure the health of the mother prior to becoming pregnant.23
It encompasses the identification and management of both chronic (e.g., diabetes) and acute (e.g.,
reproductive tract infections) medical conditions that may negatively affect prenatal health and pregnancy outcomes; health education and promotion; nutritional counseling; and identification of
women with unhealthy behaviors, such as smoking or substance abuse problems, and referral to
care. These services are focused on mitigating or preventing insults to fetal development, in some
cases often before a woman realizes she is pregnant.24 There are no reliable data on the extent to
which women receive preconception care, but it is believed to be infrequent and most likely
obtained by women with chronic diseases or by healthy, health-conscious women.
Early use of prenatal care has increased in recent years among U.S. women, rising from 76
percent in 1991 to 82 percent in 1996.3 Although African-American and Hispanic women continue
to start care later and get less care, the rise in early use of care in 1996 was greatest for them.3 There
is consistent evidence from a number of quasi-experimental studies that provision of comprehensive prenatal care is associated with reductions in LBW rates.25-29 This care includes not only the medical components of prenatal care, but also ancillary services, such as social and nutrition services,
health education, and outreach and home visiting, as needed. The effect of particular components
of prenatal care on pregnancy outcomes, however, needs to be addressed in future research.
Estimates of costs associated with antenatal hospitalizations should be included in studies of the
cost-effectiveness of prenatal care.
Early Discharge of Mothers and Newborns
The length of maternal postpartum hospitalization and the nursery stay of the baby has
declined over the past decade due, in part, to changes in medical practice, reimbursement, and
patient preferences. Shortages of hospital beds and a trend toward demedicalizing childbirth also
have contributed to early discharge practices.30,31 Although early discharge may benefit maternalinfant bonding, it may negatively affect maternal well-being due to the reduced period of rest and
to possible lack of confidence about infant care. The increased medical needs in the days after birth
(e.g., neonatal jaundice, maternal infection, breakdown of episiotomy), completeness of newborn
metabolic screening practices, and the reduction in time for in-hospital teaching and support (particularly in relation to breastfeeding) also raise concerns about the effects of early discharge.32-35
Despite these concerns, no consensus on the maternal and newborn consequences of early discharge exists.32,36-39
Technological Advances
In the past few decades, medical advances have been made in prenatal diagnosis, assisted
reproductive technologies, prediction of preterm delivery, and extension of newborn viability. The
effectiveness of prenatal diagnosis in identifying fetal chromosomal and structural abnormalities has
26
Charting a Course for the Future of Women’s and Perinatal Health
greatly improved. Some of these technologies include: the Triple Marker Screen, used to identify
neural tube defects and Down Syndrome40 and chorionic villus sampling (CVS) and amniocentesis,
both performed to detect chromosomal abnormalities. Infertility treatment includes Gamete Intrafallopian Transfer (GIFT) to address abnormalities in the number or motility of the male sperm and
Intracytoplasmic Sperm Injection (ISCI), laboratory fertilization and subsequent placement of the
embryo in the uterine cavity. New tocolytic therapies have been used to prolong pregnancy complicated by preterm labor, but they have not been demonstrated to significantly affect the absolute
number of preterm deliveries.41
The costs of infertility technology bring new dilemmas about (1) health insurance coverage
requirements, (2) equal access to this technology by all groups of women, regardless of race and
insurance status, and (3) the potential consequences for newborns who require high-cost, long-term
outpatient care and special education. For example, fertility treatments may lead to increases in multiple births, which, in turn, increases the risk for compromised birth outcomes. In 1996, 16 percent
of neonatal deaths nationally were to multiple births; they were 7 times more likely to die in the
first month of life than singleton births.42
The development and availability of improved therapies in neonatal intensive care, which
primarily serves very low birthweight (VLBW) infants (less than 1500 grams) and normal weight
newborns with life-threatening complications, are believed to be largely responsible for the dramatic
decline in infant mortality rates in the last 30 years. In particular, neonatal mortality rates have
declined markedly during this time period for the very smallest newborns.
Quality of Care
Along with advances in medical technologies, there has been increasing national debate
about the quality of health care services and guidelines for clinical care. A long history of established clinical guidelines for prenatal care exists. The American College of Obstetricians and
Gynecologists (ACOG) Committee on Obstetric Practice and the American Academy of Pediatrics
(AAP) Committee on Fetus and Newborn (1997) have collaborated in publication of Guidelines for
Perinatal Care. These guidelines are comprehensive and represent the orientation of a variety of
disciplines within the perinatal health care system. They also stress flexibility in their implementation to address local population characteristics, resources and the environment for providing care.43
Despite these AAP/ACOG guidelines, the provision of and access to perinatal services has
been found to vary by maternal characteristics, with minority and low-income women generally
receiving fewer services. The quality of ambulatory prenatal care and the use of procedures such
as amniocentesis and ultrasound or therapies such as corticosteroids have been shown to differ significantly by socioeconomic status and race/ethnicity.44-46 Lack of implementation of clinical guidelines may lead to unnecessary hospitalizations and additional health care costs.9 Research is needed to assess providers’ implementation of clinical guidelines for prenatal care, to determine the
extent to which patient preferences as well as provider non-compliance may influence the content
of care, and to identify areas of patient management that are affected by provider uncertainty
regarding efficacy and long-term side effects.
Organization and Financing of Pregnancy Care
Major changes have occurred over the past decade in the organization and delivery of pregnancy care services, particularly with regard to financing, with parallel efforts to expand insurance
coverage for pregnant women and to reduce costs within the overall health care system through
managed care strategies.
27
Charting a Course for the Future of Women’s and Perinatal Health
In the late 1980s, the Medicaid program was expanded for pregnant women and their newborns largely in three areas: broadening the eligible population; simplifying and shortening the eligibility process, and enhancing services provided to program beneficiaries (e.g., covering nutrition and
case management services). The percentage of women with no health insurance at the start of pregnancy dropped from 26 percent in 1985, before the Medicaid expansions, to 19 percent in 1994.2,47
Recent national legislative initiatives regarding health insurance are likely to both positively and negatively affect the affordability of and access to perinatal care by women. The Health
Insurance Portability and Accountability Act of 1996 provided new insurance protection for individuals who move from one job to another, who are self-employed, or who have pre-existing conditions. The provisions, which prohibit denial of benefits to pregnant women and application of preexisting condition exclusions or waiting periods for newborns or adopted children, increase to some
degree women’s flexibility in making decisions about employment while pregnant.48
The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA)
eliminated most public benefits for both legal and undocumented immigrants, including Medicaid
coverage of prenatal care and delivery services. Concurrent changes in immigration policy compound this situation by creating disincentives for accessing prenatal care. Inadequate prenatal care
may lead to increased morbidity in the infants of immigrant women. As a result, the cost savings
resulting from the exclusion of immigrant women from Medicaid may be offset by increased costs
for neonatal care.49 The delinking of welfare/workforce status with Medicaid has raised serious concerns and stimulated policy initiatives encouraging outreach and collaboration. Title V Maternal and
Child Health programs, Community and Migrant Health Centers, and other local and state public
health programs seeking to serve this population, however, are facing increased demand at a time
when resources and capacity for direct services provision are diminishing. The PRWORA legislation
illustrates the need to vigilantly monitor population health status and to institute new processes for
system responses to overcome unintended consequences of national policy changes.
While the percentage of pregnant women enrolled in managed care plans is unknown,
enrollment of all Medicaid recipients rose nationally from 9.5 percent in 1991 to 47.8 percent in
1997.50 The growth of managed care may have both positive and negative impacts on pregnancy
care. While managed care organizations (MCOs) are traditionally oriented towards providing comprehensive, cost-effective care and coordination of services,51 there is also concern about limited
choice of providers, limited physician-patient interaction, limited access to specialist care, and discontinuities in providers due to MCO contracting practices.52 The development of public-private
partnerships in communities may be an important strategy for ensuring quality care for women
enrolled in managed care plans, while maintaining the presence of population-based services for
which public health plays such an important role.
Regionalization of Systems for Perinatal Care
Regionalization of perinatal care was successful in the 1970s and early 1980s in concentrating VLBW births in tertiary centers, reducing neonatal mortality rates for these infants, and
improving overall neonatal mortality rates for the entire population.53 A rise in Level II (specialty),
and to a lesser extent self-designated Level III (subspecialty) hospitals, is thought, in part, to be a
result of competition for perinatal patients. Moreover, the number of neonatologists has increased
considerably in recent years, yielding more specialists to staff the newly designated Level II and III
facilities.54 These changes have occurred without a concomitant improvement in survival rates for
VLBW infants in Level II facilities.55 There also is concern about differential access to high-risk perinatal care dependent upon socioeconomic status. Methods of monitoring and measuring the impact
of regional systems of care must be developed and implemented to assure the equitable and costeffective distribution of resources for pregnant women and newborns.
28
Charting a Course for the Future of Women’s and Perinatal Health
The health services delivery and financing changes in the 1990s highlight the importance
of a locus of accountability for the total population, which can be illustrated in perinatal regionalization by the establishment of community boards. These boards are instituted to assure access to
care in the community by coordinating services for all pregnant women and newborns residing
within a defined geographic area, regardless of income or insurance status, and to assure access to
risk-appropriate care by instituting procedures for monitoring and surveillance. Studies are needed
to evaluate various approaches to establishing a locus of accountability and their effect on access
of women to risk-appropriate care and other needed services.
Women’s Experience of Chronic Diseases†
A wide range of chronic conditions may affect a woman across her lifespan. Although
women may live longer than men, they experience earlier morbidity and utilize health services at
higher rates than men. National
Health Interview Survey (NHIS)
data reveal that as women
NUMBER OF SELECTED REPORTED CHRONIC
progress from adolescence
CONDITIONS PER 1,000 WOMEN, UNITED STATES, 19952
through the childbearing years
to menopause, the incidence
CHRONIC CONDITION
<45 YEARS
45-64 YEARS
and prevalence of chronic conditions rise.1 Asthma, diabetes,
Asthma
61.0
73.6
hypertension, and thyroid disorders are among the most freHypertension
30.3
212.9
quent chronic conditions that
limit activity in women of childDiabetes
9.7
65.4
bearing age.
Thyroid Disorders
14.2
48.3
(including goiter)
RACIAL COMPARISON, RATES PER 1,000 PERSONS2
CHRONIC
DISEASE
BLACK
WHITE
Under 45
years
45-64
years
Under 45
years
45-64 years
Asthma
69.0
60.0
61.0
52.5
Hypertension
46.1
344.7
30.1
207.8
Diabetes
8.8
121.4
7.1
55.8
Thyroid Disorders
(including goiter)
3.0
29.9
9.4
29.6
The burden of chronic diseases falls disproportionately on two overlapping subpopulations of women: poor
women and minority women.
In a study of low-income,
African-American women of
childbearing age, more than
25 percent of women reported
a chronic illness (i.e., diabetes,
hypertension, asthma, or any
other condition requiring routine therapy with medication).3
†
Material adapted from Misra in Charting a Course for the Future, Volume II.
29
Charting a Course for the Future of Women’s and Perinatal Health
Predictors of Chronic Disease
For each of the chronic diseases discussed, a unique set of predictors for disease can be
identified. However, a number of factors contribute to multiple chronic diseases:
❖
nutrition — both the components (food groups) and total calories can have a large impact
on risk for several chronic conditions;4-6
❖
smoking — a well-documented, significant contributor to poor health;7,8
❖
physical activity — low
levels may influence the
COMMON CHRONIC CONDITIONS IN WOMEN, ALL AGES, 1990-19921
risk for obesity and comOne or more
Average annual
promise heart and lung
Chronic
Limitation of
Hospitalizations
number
per
function, all of which
Condition
Activity (%)*
(%)*
1,000
may predispose a woman
to diabetes mellitus and
Asthma
48.1
22.2
21.7
hypertension;9-15
Hypertension
120.1
11.8
8.3
❖
stress — may influence
the health of those
Diabetes
30.6
35.7
27.0
women who are already
experiencing some form
Thyroid Disorders
22.0
6.9
12.8
(excluding goiter)
of chronic disease.16
*Among women with the condition.
Consequences
In 1994, 10 percent of women ages 18-44 reported at least some limitation of activity
due to chronic conditions.17 These limitations, as well as the demands entailed by effective selfmanagement of a chronic disease, may have profound consequences on family functioning and
on the quality of women’s lives.
Recent trends indicate more women are postponing childbearing into their late thirties and
forties. The increase in the prevalence of chronic diseases in older age both highlights and heightens the importance of addressing chronic diseases throughout a woman’s lifespan, but especially
during pregnancy.
Chronic diseases have the potential to adversely affect pregnancy outcomes due to complications of untreated disease or even to treatment itself.18 Furthermore, unlike an acute exposure,
a chronic disease can affect a woman from the time of conception until the time of delivery.19
Pregnancy may also affect the chronic condition, although adverse effects are not consistently
observed. In addition, women may experience differing effects and offer differing levels of adherence to medical regimens at various points during pregnancy.
Interventions
Women in general use a variety of providers to meet their health care needs. Over one-third
of U.S. adult women use both an obstetrician-gynecologist and another primary care physician for
their regular health care needs,20 highlighting the need for coordinated care. Although a higher percentage of women rely on a single provider, such as a family practitioner, internist, or obstetriciangynecologist, for regular care,20 women with chronic conditions are likely to see specialists for services in addition to their regular care. In addition to the problems associated with uncoordinated
care, women’s multiple roles and limited time for self-care challenge providers in their efforts to
help women follow through with their complex therapeutic regimens.
Health education and awareness initiatives can be used to prevent the onset of chronic diseases and minimize their negative consequences. Providers have the opportunity to screen and
30
Charting a Course for the Future of Women’s and Perinatal Health
teach their patients about appropriate health behaviors in addition to prescribing appropriate disease management regimens. Provider-patient encounters, whether for well-woman care, preconception care, prenatal care, or other types of health care visits, represent “teachable moments” that
providers can capture to improve the health of their patients. Women may become more health conscious during pregnancy and may therefore be more receptive to health education messages regarding self-care for chronic diseases.
Screening for chronic conditions must be part of the package of routine prenatal care services. Early phases of chronic diseases may not be apparent, and many women, particularly poor
and minority women, have had little contact with the health care system prior to pregnancy. The
prevalence of chronic disease has implications for maintaining effective systems of regionalized care
wherein women can receive adequate attention to their chronic health problems. Any economic or
other disincentives to refer mothers to specialty care must be addressed. Prenatal care may also be
an important bridge to a relationship with another health care professional who can provide ongoing care for the woman’s chronic condition after pregnancy.
The inherent difficulties of studying chronic disease in the context of pregnancy, such as
the relative infrequency of occurrence of these conditions, have prevented researchers from focusing on it as a risk factor. Studies of the effects of chronic disease on pregnancy outcomes are needed, particularly studies that go beyond the case series methodology and that include the many
women with chronic conditions who are not under the care of a specialist. The current knowledge
base lacks information to determine whether there are gender differences in the effects of therapeutic regimens for chronic diseases, and whether therapeutic effects differ at various points in a
woman’s menstrual cycle.
Depression in Women†
Depression in women is a significant health problem due to its relatively high prevalence,
its high rate of recurrence, and its often profound effect on functioning. Recent demographic
changes that impact women’s ability to support their families and reconcile conflicting work and
family roles — rising numbers of single mothers, increasing participation in the workforce, and
decreases in welfare caseloads — may increase the prevalence of depression in women.
Depression affects twice
as many women as men.
CURRENT AND LIFETIME PREVALENCE OF MAJOR
Estimates of prevalence among
(CLINICAL) DEPRESSION IN WOMEN, BY
women range from 6 percent for
RACE/ETHNICITY2
one-month risk of a major depressive episode to 11 percent for
RACE/ETHNICITY
ONE-MONTH (%)
LIFETIME (%)
depressed mood. About 10 perWhite
5
22
cent of pregnant women1 and 15
percent of women in the postparAfrican-American
6
16
tum period experience depres2-4
sion. The lifetime risk of major
Hispanic
11
24
depression among women may be
as high as 21 percent.2,3,5 Since
World War II, rates of depression have risen and the average age of onset has dropped. Rates of
depression are highest among women under the age of 25.2
†
Material adapted from Ruderman and O’Campo in Charting a Course for the Future, Volume II.
31
Charting a Course for the Future of Women’s and Perinatal Health
Risk Factors for Depression in Women
Depression is analogous to fever, in that it is the singular manifestation of multiple disease
processes.5-7 No one risk factor will sufficiently explain its origin; it is more likely that depression
results from an interaction between biological and environmental, or psychosocial, factors, with the
contribution of each varying by case.5-8
Psychosocial factors: Many of the factors associated with depression in women speak to the mental
health effects of the social position of women, including:
❖
sex-role stereotypes that foster passivity and “learned helplessness,” and sex-role expectations that limit women’s opportunities and contribute to low self-esteem;
❖
minority ethnic or racial group or low social class, which may be associated with discrimination, acculturative stress, and increased likelihood of poverty-related life stressors;
❖
physical or sexual abuse, both highly prevalent among women;
❖
sexual orientation, which entails stressors related to both disclosure (e.g., job discrimination) and non-disclosure (e.g., secrecy, threat of exposure); and
❖
degree of parental responsibility and conflicting work and family roles.
Marriage and employment seem to be protective factors for women, with some exceptions.
An unsupportive spouse and employment in traditionally male-dominated professions have both
been associated with increased risk of depression in women.9-11 A sense of control over one’s environment is also important for positive mental health.9,12
Biological factors: Several biological factors have been implicated in the etiology of depression:
❖
genetics;
❖
abnormalities in neurotransmitter activity, particularly norepinephrine and serotonin; and
❖
malfunctions or fluctuations in the endocrine system, such as impaired neurological control
of cortisol secretion, decreased thyroid-stimulating hormone and growth hormone, and
changes in female sex hormones associated with reproductive events.
Before puberty, there is no gender disparity in rates of depression, possibly lending weight
to an endocrinological explanation for the disproportionate burden of depression in women.13,14
However, puberty entails both biological and psychosocial changes that may contribute to depression.
Pregnancy and childbirth may be “triggers” for onset in women already vulnerable to
depression.15 Postpartum depression is associated with personal or family history of depression,
although for most cases there is no such history. Postpartum depression is not wholly biological in
origin; levels of emotional support and available assistance with caretaking and household tasks are
related to the risk of depression.4,15,16 The risk factors for prenatal depression are similar to those for
postpartum depression and include personal or family history of depression, marital problems,
young maternal age, and unwanted pregnancy.17
Consequences and Costs of Depression
Depression tends to be recurrent. At least half of those who experience a single episode of
depression will experience another, and the likelihood of recurrence rises with each subsequent
episode.18 Moreover, depressive episodes often occur in the context of chronic subclinical symptoms.19
Depression can severely impair both social and occupational functioning and is associated
with increased physical illness.5,18,20 Moreover, the death rate from suicide is as high as 15 percent
among the severely depressed.18 Untreated depression during pregnancy can lead to poor nutrition,
poor sleep, substance abuse, and inadequate prenatal care.21
32
Charting a Course for the Future of Women’s and Perinatal Health
The economic repercussions of depression on a societal level are great and should lend
urgency to the need for public policy addressing its prevention and treatment. Costs associated with
depression and related affective disorders, including both the direct costs of treatment and the indirect costs of lost productivity due to impaired functioning or premature death, totaled as much as
$30.4 billion in 1990.22 Currently, about two-thirds of cases of depression go untreated; another $610 billion would be added to the direct costs of treatment if all of the estimated 25 million people
with affective disorders received treatment. However, because people with depression use more
medical services,5 the costs of treatment would be offset by a 20 percent decrease in per capita
health care expenditures, saving nearly $4 billion.23
Interventions
Increasingly, pharmacologic treatments are being used to combat depression.24 Although a
small body of evidence suggests that antidepressants are less efficacious in women than in men,8,25
most antidepressant prescriptions are written for women.7 While antidepressants provide a powerful remedy for women experiencing clinical depression, the need to address structural/environmental issues remains, both in individual treatment and on a population level.
Successful interventions will address women’s multiple roles and responsibilities and take
into account cultural differences in the expression and management of depression.26,27 Given the part
sex-role socialization and low self-esteem plays in the etiology of depression, interventions aimed
at stemming the risk of depression before the onset of symptoms might involve building a healthy
and resilient self-image in young girls and helping them to exert positive control over their environments.11,13 On a broader level, efforts to alleviate the effects of poverty, of gender and racial discrimination, and of conflicting work and family roles should favorably impact both women’s mental and physical health.
Most incident cases of clinical depression are preceded by subclinical depressive symptoms,
suggesting the opportunity for early intervention and prevention of some of the more disabling
forms of illness.19 Currently, about one-half of all cases of depression go undetected by primary care
physicians.24,28,29 These providers, who treat the majority of cases of depression, would benefit from
improved training in the detection and treatment of mental health disorders.
The financing of mental health services is an increasingly important policy issue. The most
severely ill and the most financially disadvantaged may be the most negatively affected by cost-containment strategies in health care financing and delivery.29 Medicaid and Medicare reimbursements
for mental health services are lower than private insurers’ rates.30 With the increasing prevalence of
managed care organizations, referrals for mental health services may be limited and pharmacologic
interventions may be used inappropriately to reduce the scope and costs of treatment.24,28,30,31 In addition, mental health carve-outs may pose a threat to coordination of enrollees’ care through primary care providers.28,30
Although insurance plans are prohibited by law from setting caps on mental health benefits lower than caps on medical benefits, most fee-for-service insurance plans have greater restrictions and higher co-payments for mental health services than for medical services.30 Many plans also
exclude coverage of mental disorders as preexisting conditions.30 Recent legislation restricts the
exclusion of preexisting conditions to 12 months after enrollment, including time enrolled in a previous plan for individuals who have had continuous coverage. However, for women who have not
had continuous insurance coverage, a 12-month break in treatment can have serious ramifications.
Finally, greater restrictions on “mental” versus “medical” therapies are particularly burdensome for
pregnant and lactating women, for whom pharmacologic treatments may be contraindicated.32
33
Charting a Course for the Future of Women’s and Perinatal Health
Women account for nearly three-quarters of prescriptions for drugs used to treat mental illness, and there are known gender differences in physiology that influence drug metabolism. Still,
knowledge is limited about gender differences in the effects of many pharmaceutical interventions.
The knowledge base should be expanded regarding the effect of gender on outcomes of treatment,
including efficacy and side effects of antidepressants. Particular focus is warranted in this regard on
the effect of pregnancy on dose requirements, changes in treatment during pregnancy and lactation,
and the long-term effect of exposure to anti-depressants in utero and in breastmilk. The contribution of social factors to women’s depression—such as socioeconomic status and multiple work and
family roles—should be further explored, with an eye to determining mechanisms of action.
Abuse Against Women by Their Intimate Partners†
In recent decades, society has become aware of the need to address both the causes and
consequences of domestic violence against women.1 Abuse of women has serious ramifications
because of its prevalence, the effects on children in the household, and the long-term emotional
and physical consequences for women and their families. Up to 75 percent of lone-offender violence committed against women is perpetrated by someone known to the women. On average, from
1987-1992, 27 percent of all victimizations of females were committed by intimates, and about 5.5
females are victimized by sole offenders per 1,000 population. Surveys reveal that intimate partners
batter two million women and kill 1,500 annually.
Violence against women is a major social problem in the United States, yet research on the
determinants, prevention, and solutions is still in its early stage. Providers of health care, historically slow to both recognize and develop a response to domestic violence, now acknowledge violence
against women as a major cause of premature mortality. A chapter of the Healthy People 2000
Objectives is devoted to violence, providing official recognition of the need for health professionals
to address this issue.
Trends in Fatal Violence
❖
❖
❖
In 1993, one-third of female homicide victims were murdered by their spouses, ex-spouses,
or boyfriends.1
While the rate of homicide by an intimate partner has decreased for males over the last two
decades, the rate for women has remained relatively stable at around 1.6 per 100,000 population.2
Seventy-four percent of all homicides of men and women are committed using firearms,
and the risk of homicide by a family member or intimate is almost eight times higher if a
gun is kept in the home.3
Trends in Non-Fatal Violence
Occurrences of non-fatal violence, which encompass physical, sexual, and psychological
violence, are thought to be underreported, particularly in routine sources as opposed to research
studies. Even so, the numbers of reported occurrences of physical violence range from 9 per 1,000
women to 220 per 1,000 women.1
❖
Attacks perpetrated by intimate partners on women result in a 50 percent injury rate, compared to an injury rate of only 20 percent for attacks on women by strangers.1
†
Material adapted from O’Campo and Baldwin in Charting a Course for the Future, Volume II.
34
Charting a Course for the Future of Women’s and Perinatal Health
❖
❖
In one study, women with unwanted pregnancies had over four times the risk of experiencing violence by a partner than women with intended pregnancies.4
At least 50 percent of abused women do not report the abuse to anyone.5
Determinants and Risk Factors
A variety of factors have been identified as determinants of domestic violence, including
poverty, economic deprivation, and exposure to other stressors such as racial discrimination; educational
and occupational status differences in which the woman holds the higher position; patriarchal social
norms reinforcing male power over female partners; pathological personality characteristics of the
perpetrator or poor coping skills; and substance abuse by the victim or perpetrator. Several risk factors have also been identified, including young age, social isolation, pregnancy and the early postpartum period, and previous abusive relationships.
Consequences
The consequences of physical and psychological violence are severe and often long-term
and include: mortality, physical and psychological morbidity, lost productivity and income, and
social isolation. The medical consequences of physical violence may be underreported, as most
women do not disclose their abuse to health care providers.5 Pregnant women who experience
abuse are at risk for spontaneous abortion, premature delivery, low birthweight infant, and depression.6-8 Although the economic consequences of domestic violence are difficult to accurately portray,
estimates of both direct and indirect costs are considerable, ranging from $5 to $67 billion annually.9
Interventions
Current activities utilized to prevent violence against women include arrest of male perpetrators, mandatory reporting (which varies from state to state),10 counseling programs, state and federal statutes that limit access to handgun purchase, and provision of protective and social services
for victims of abuse.
There are currently no primary prevention strategies aimed at alleviating risk before the onset
of domestic violence. Rather, selected protective and support services are available for crisis intervention once women have experienced abuse. Evaluations of interventions targeting batterers have
been fraught with methodological problems.11 To date, these programs have not proved effective in
reducing violent behavior.12,13 Rigorous research and evaluations therefore are needed to identify successful batterer interventions. More research also is needed to determine whether and how existing
protective and social support services have short- and long-term benefits for victims of violence.
Several national strategies currently being employed may serve to decrease the incidence
and stem the negative effects of domestic violence, including the Family Violence Option, a provision of Temporary Assistance for Needy Families (implemented in 28 states) that exempts those
women who have experienced domestic violence from the federal five-year lifetime limit of welfare
benefits, as well as federal laws prohibiting persons convicted of domestic violence by a jury trial
from owning or possessing firearms.14 Coalitions between women’s and children’s advocacy groups
have formed to address issues of joint concern, such as the fragmentation in the legal system that
often complicates the preservation of the mother-child unit in cases of domestic violence.15
Health professionals have an opportunity at each well-woman check-up and prenatal care visit
to screen and refer women for domestic violence treatment, something they often fail to do because
35
Charting a Course for the Future of Women’s and Perinatal Health
of embarrassment, time constraints, and inadequate training.16 In addition, the threat of termination or
denial of insurance for victims deters clinicians from recording abuse in medical records.1,17
Additional research is needed to determine pregnancy-related factors leading to the increased
risk of abuse prenatally, and the extent to which pregnancy results from sexual abuse. To date, the
causal determinants of partner-perpetrated violence, the effectiveness of protective and social support
services for victims, and the effectiveness of current interventions for batterers warrant further study.
The Nutritional Status and Needs of Women of Reproductive Age†
The nutritional status of an adult woman is the culmination of nutrient intake, metabolism,
and utilization over the course of a lifetime, beginning with her nutritional status at birth.1 Weight
at birth is a proxy indicator of nutritional status in utero and may be linked to health problems later
in life, such as cardiovascular disease, hypertension, and cancer. Poverty is related to poor nutritional status, usually due to factors limiting food access. Nutritional insults resulting from poverty
are important since the effects are cumulative. Adolescence is a time when food habits are finalized,
laying the foundation for adult nutritional status. Nutritional problems among American women are
reflected in high rates of overweight and obesity as well as eating disorders that can lead to underweight and compromised nutritional status.
Specific nutritional deficiencies affect women as well as their offspring. Smoking, not performing load-bearing exercise, and poor diet during the period of maximal bone mineralization are
all associated with inferior bone health.3 In addition, U.S. women suffer from iron and folate difficiencies and eating and weight disorders:
❖
The prevalence of iron deficiency anemia in women was 4-10 percent in 1976-1980.4
❖
Folate deficiencies prior to and during pregnancy lead to neural tube defects in 2,500 infants
annually.5
❖
It is projected that 50,000 U.S. lives each year may be saved by increasing folate to prevent
high levels of homocysteine, a factor for heart disease and stroke.6,7
❖
Anorexia and bulimia affect women of all races and socioeconomic strata. Among young
women, there is a 1 percent prevalence of anorexia and a 4-20 percent prevalence of bulimia.8
❖
Only 30 percent of pregnant women gain
PERCENTAGE OF OVERWEIGHT AND
weight within Institute of Medicine recommenOBESITY IN WOMEN ≥20 YEARS OLD
dations.9
(AGE ADJUSTED)2
Predictors and Risk Factors
RACE AND HISPANIC
1988-1994
ORIGIN
Johnson (1996) describes five societal factors
that shape women’s eating patterns: (1) employment
White, non-Hispanic
45.5
outside the home — by the year 2000, an estimated 50
Black, non-Hispanic
66.5
percent of the workforce will be women and 60 perMexican American
67.6
cent of women will work outside the home, concomitant with a large increase in the number of working
All Women
49.6
women with young children (less than 6 years old);
(2) increased consumption of prepared foods that are higher in fat and sodium than home-prepared
foods; (3) an increase in single female-headed households (55 percent of these families live in
poverty and, as a result of limited resources, eat less fresh fruits and vegetables); (4) increased number of meals eaten away from home, with the associated increased fat, sodium, calorie, and cholesterol intake, and decreased iron, calcium, vitamin C, and fiber intake; and (5) increased tobacco
use and consequent poor eating habits.10
†
Material adapted from Bronner and Baldwin’s work on nutrition in Charting a Course for the Future, Volume II.
36
Charting a Course for the Future of Women’s and Perinatal Health
Economic necessity, desire for personal and professional fulfillment, and welfare-to-work
legislation are associated with record numbers of women in all age groups being employed and
burdened by the multiple responsibilities of employment, child care, and home management.11
Working women continue to be the primary person managing the household (cooking, cleaning,
caring for children, etc.) in addition to working full-time.12 In both single, female-headed households
as well as in married households, the burden of these multiple roles has resulted in a decrease in
time available for food shopping and meal preparation, and, in turn, to changes in food consumption patterns.
Risk factors for overweight and obesity include physical inactivity, middle age (30-60 years
of age), low socioeconomic status, acceptance of larger body image as ideal, minority race, genetic predisposition, family history, high fat diet, and multiparity. In contrast, risk factors for anorexia
and bulimia include adolescent/young adult age, high socioeconomic status, White race, very small
body image as ideal, extreme levels of physical activity, controlled dietary intake low in calories and
nutrients, family history, and unrealistic achievement expectations. Poverty, low educational attainment, high parity, and smoking are all factors placing women ages 20-44 at greater risk for iron deficiency anemia.4
Consequences
Obesity is related to increased morbidity from chronic diseases, such as diabetes, cardiovascular disease, osteoarthritis, and some forms of cancer, as well as depression, low self-esteem,
menstrual cycle irregularities and infertility problems.13 Low and underweight women are more likely to have bone mass and bone structure loss and have an increased risk for osteoporosis, chronic
fatigue, and fertility impairment.14
Low intake of several nutrients is associated with poor health outcomes: in addition to neural tube defects in fetuses and infants,5 folate deficiencies can contribute to cardiovascular disease;15
low intake of iron is associated with anemia; low dietary intake of calcium during adolescence and
early adulthood is associated with lower peak bone mass levels and possibly an increased risk of
osteoporosis.16
Interventions
Interventions to prevent and reduce obesity include decreased energy intake, increased
exercise, behavior modification, and pharmacotherapy as needed. While federally-funded food and
nutrition programs fill gaps in women’s nutritional intake, non-pregnant women are less likely to
see a physician regularly for prevention and education. Creative strategies therefore are indicated to
improve this population of women’s nutritional status. Moreover, it is crucial to implement these
strategies at the earliest age possible in order to initiate healthy, preventive behaviors regarding, for
example, obesity and osteoporosis. The National Institutes of Health is working with institutions
such as schools to develop strategies useful to prevent obesity.17 Clinics also may contribute to
increased access to nutritional screening. The National Heart, Lung, and Blood Institute has produced a set of culturally appropriate nutrition education materials for community-based interventions, and the Centers for Disease Control and Prevention is merging its physical activity and nutrition programs to effect change in the prevalence of obesity in the country. Strategies have yet to be
developed, however, to meet the recommendations of the American Health Foundation’s Expert
Panel on Healthy Weight.
Interventions are hampered by gaps in the knowledge base. To increase folate intake, the
Food and Drug Administration requires fortification of grain products with between 0.43 and 1.4
37
Charting a Course for the Future of Women’s and Perinatal Health
mg folate per pound of product.18 The potential negative consequences of population-wide food
supplementation recommendations, however, remain a concern. Thus it is important to assess the
extent to which folic acid supplementation and fortification programming impact folate nutritional
status and consequent incidence of neural tube defects. In order to further advance the knowledge
base related to nutrition, it is important to evaluate the impact of various initiatives and insults on
the nutritional status of women, such as the guidance for calcium intake regarding bone mineral
density and the impact of stress from multiple role “overload.”
Women’s Physical Activity in Leisure, Occupational, and Daily Living Activities†
In
recent
years, greater attenREPORTS OF PARTICIPATION IN PHYSICAL ACTIVITY,
tion has been focused
FEMALES AGE 18+ YEARS1
on the relationship
No
Regular,
Regular,
Year
between
women’s
Activity (%)
Sustained Activity (%) Vigorous Activity (%)
physical activity and
1986
34.3
18.1
18.8
their overall health.
The prevalence of
1988
31.5
19.6
20.0
women’s participation
1990
32.3
18.5
19.4
in physical activity has
1992
31.4
18.4
19.7
increased, due in part
to the implementation
1994
33.0
18.1
18.7
of recommendations
made by national organizations1 and implementation of the Title IX Education Amendments of 1972,
which provides for equal opportunity for women in sporting activities in schools. Despite these
advances, only 20 percent of U.S. adult women participate in regular and vigorous exercise.1
Health-Related Benefits and Concerns Associated with Physical Activity
Moderate intensity activity performed for 30 minutes on most days of the week is associated with a number of health-related benefits:
❖
Decreased risk of developing cardiovascular disease.2-6
❖
Decreased risk of developing non-insulin-dependent diabetes mellitus.7-9
❖
Decreased risk of osteoporosis.1,10-12
❖
Weight management and obesity prevention.
❖
Increased proportion of muscle mass to fat mass.1,13-18
❖
Reduced stress levels and improved mood. Inactive persons are reported to be as much as two
times more likely to experience symptoms of depression than physically active individuals.1
❖
Availability of physical activity contributes to attendance at smoking cessation sessions, and
long-term quit rates are found to be higher for women participating in exercise sessions.19
Current research results neither support nor refute a relationship between physical activity
and hormone-dependent cancers in women; some studies do however indicate that physical activity may be protective against breast cancer.20
†
Material adapted from Bronner and Baldwin’s work on physical activity in Charting a Course for the Future, Volume II.
38
Charting a Course for the Future of Women’s and Perinatal Health
Physical activity can also negatively affect women’s health. Exercise done improperly can
result in musculoskeletal injuries, metabolic abnormalities (e.g., hyperthermia, electrolyte imbalance,
and dehydration for those who exercise in extreme conditions or for excessive periods of time),
anovulation, amenorrhea, and decrease in bone mass.1 Efforts by women, especially young women
at puberty, to balance good health, peak performance (for athletes), and appearance result in the
“female athlete triad,” consisting of disordered eating, amenorrhea, and osteoporosis.21 Excessive
exercise contributes to this triad.22,23
Physical Activity During Pregnancy and Lactation
Physical activity can have both positive and negative implications for lactating or pregnant
women and their offspring. Exercise during pregnancy and lactation may be associated with
changes in uterine blood flow, hyperthermia, metabolism of energy nutrients, fetal hypoxia, and
uterine contractility, all of which may increase the risk of preterm delivery.24,25 Overall, exercise during pregnancy does not appear to have significant positive or negative affects on fetal well-being,
but can improve maternal cardiorespiratory fitness, and may increase maternal well-being.1,26
Exercise during lactation is not associated with significant differences in maternal body weight or
fat loss, volume or composition of breast milk, or infant weight gain.27 However, physical activity is
associated with a small but significant decrease in weight retention at 7 to 12 months postpartum.28
Interventions to Enhance the Physical Activity Behavior of Women
Research has identified several psychological, social, and environmental variables that are
associated with patterns of physical activity behavior. Marcus and Forsyth (1998)29 cite several psychological theories that can contribute to the tailoring of a physical activity intervention:
❖
Motivational readiness points toward using a cognitive intervention rather than a behavioral
strategy depending upon what stage of motivation (e.g., precontemplation, contemplation,
preparation, action, or maintenance) a person is in.
❖
Decisional balance refers to the careful consideration of the pros and cons of choices in
activity.
❖
Self-efficacy, relating to a person’s confidence in being able to successfully perform a specific behavior.
❖
Social support for an intervention can be informational, instrumental, motivational, or modeling.
Tailoring an intervention according to these theories, personal activity preferences, environmental factors such as safety and access, and a woman’s stage in life may improve the likelihood
of effectiveness. Providing information so that women are aware of the health benefits of physical
activity, helping them acquire skills in physical activities that can be practiced for a lifetime, and
providing facilities where women will be comfortable are all important to increased participation.
Additional methods to increase access to physical activity are to accommodate women’s multiple
roles, using work sites to promote and provide opportunities for physical activity, and making work
sites as well as community facilities, such as schools and religious institutions, available during nonbusiness hours. Generally, health care providers do not assess for level of or opportunities for physical activity. Primary care providers and other allied health professionals who interact with women
around issues of health promotion should encourage appropriate levels of physical activity, and
there should be reimbursement for provider counseling.
There currently exists a dearth of information on the effects of physical activity on
women’s (especially minority women’s) health, and many relationships remain unclear. We do not
fully understand the impact of physical activity on weight reduction and maintenance, nor the relationship between type, intensity, and duration of physical activity on fitness, health and normal
39
Charting a Course for the Future of Women’s and Perinatal Health
developmental stages (i.e., symptoms of menopause), and disease in women. We need to examine
barriers to participation in physical activity according to a number of factors, especially social class
and ethnicity, as well as by number and type of work and caretaking roles, and design interventions to increase the level of physical activity in women, particularly those that enhance and maintain muscular strength, muscular endurance, and flexibility through the perimenopausal period.
Effects of Drug and Alcohol Use on Women’s and Perinatal Health†
Illicit drug use among
women has received increased
attention as a health problem
during the last three decades,
particularly, but not exclusively,
with regard to use during pregnancy. Nearly 50 percent of
American women ages 15-44
have used illicit drugs at least
once in their lifetime.1 The peak
age for use among women parallels the peak childbearing
years, 15-44 years of age, which
is of special concern due to the
risks to the fetus. Marijuana is
by far the most commonly used
illicit substance by women in
this age group.
USE OF ALCOHOL IN THE MONTH BEFORE THE SURVEY (%)4
YEAR
FEMALE
MALE
Ages
12-17
Ages
18-25
Ages
12-17
Ages
18-25
1976
29
58
36
79
1979
36
68
39
84
1982
27
61
27
75
1985
29
65
34
78
1990
24
53
25
74
1992
15
53
17
60
USE OF MARIJUANA IN THE MONTH BEFORE THE SURVEY (%)4
FEMALE
YEAR
Ages
12-17
MALE
Ages
18-25
Ages
12-17
Ages
18-25
Alcohol is the most fre1976
11
19
14
31
quently used substance among
U.S. women. The major risk
1979
14
26
19
45
period for initiation of alcohol
1982
10
19
13
36
use is over by age 20, and
almost no individuals initiate
1985
11
17
13
27
alcohol use after age 29.2
1990
4
9
6
17
Alcohol abuse and/or dependence occurs in less than 10
1992
3
8
5
15
percent of women. Among
women, reported prevalence of alcohol abuse in 1991 was highest in White women, followed by
Black and Hispanic women. Prevalence rates for alcohol abuse in Asian women are low.3
Although most women who use alcohol begin their use early, use of hard drugs like
cocaine and heroin or chronic excessive use of alcohol occurs later.2 These findings highlight target
times for focused primary prevention programs.
The tables provided illustrate the use of alcohol, marijuana, and cocaine by young men and
women from 1976 to 1992, according to results from several years of the National Household Survey
on Drug Abuse, administered to a sample of the population 12 years of age and over in the coterminous United States by the National Institute on Drug Abuse.4
†
Material adapted from Strobino’s work on drug and alcohol use in Charting a Course for the Future, Volume II.
40
Charting a Course for the Future of Women’s and Perinatal Health
Among
adolescents,
USE OF COCAINE IN THE MONTH BEFORE THE SURVEY (%)4
family/parent connectedness,
FEMALE
MALE
perception of connectedness to
YEAR
Ages
Ages
Ages
Ages
school, high self-esteem, high
12-17
18-25
12-17
18-25
grade point average, and reli1982
1.5
4.7
1.8
9.1
gious identity have all been
found to be protective against
1985
1.4
6.2
2.0
9.0
alcohol use.5 On the other
1988
1.4
3.0
0.9
6.0
hand, higher rates of substance
use are reported for adolescents
1990
0.4
1.6
0.7
2.8
with access to substances in
1992
0.3
0.8
0.2
2.9
their homes and for adolescents
who appear older than their
school mates.5 Protective factors in adults are not known.
Consequences of Women’s Use of Drugs and Alcohol
Women who abuse alcohol and/or various illicit drugs are more likely to have poor nutrition and to experience medical problems such as elevated blood pressure, increased heart rates,
and/or sexually transmitted diseases.6-8 They are more likely than non-users to attempt suicide.8
Approximately 64 percent of reported AIDS cases among women are due to either intravenous drug
use or having sex with an intravenous drug user.7 Alcohol and/or drug abuse is also linked to incidents of sexual assault, unprotected sex, unwanted pregnancies, and domestic violence.9-11
For women, the social consequences of substance abuse include increasing likelihood of
incarceration,12 homelessness, and child abuse and neglect.6,8 Chronic heavy alcohol use has especially deleterious consequences for the health of women because of a “telescoping effect.” Women
who abuse alcohol experience higher rates of liver disease and related mortality after shorter periods of use and lower amounts of drinking than men. Mortality rates for women who abuse alcohol
are also high for suicide,8 alcohol-related accidents, circulatory diseases,13 and breast cancer.14 The
co-occurrence of mental disorders with substance abuse has been reported in a number of studies,
of which major depression, anxiety disorder, and post-traumatic stress disorder are the most common problems.15,16 Moreover, use of stimulants, marijuana, and opiates by women has been correlated with eating disorders, particularly bulimia.16
The use and abuse of alcohol and drugs before and during pregnancy has negative effects
for both women and children. More than 5 percent of pregnant women are estimated to use illicit
substances sometime during their pregnancy.17 In 1995, a higher rate of alcohol use during pregnancy was reported by women than in 1994: 16.3 percent.18 The highest reported use was in women
over 30. Women who use drugs during their pregnancies are more likely to be depressed, have
fewer social supports, have less stable living arrangements, and are more likely to drink alcohol and
smoke.19,20
Infants born to women who abuse drugs and/or alcohol during pregnancy are at increased
risk for a number of deleterious effects. For example, infants born to women who use cocaine are
at an increased risk of being born small.20 The heavy use of alcohol by women during pregnancy
has been associated with severe birth defects, such as cranio-facial abnormalities.21 Native Americans
consistently have the highest rates of alcohol use, with a concomitant increase in rates of fetal alcohol syndrome (FAS) relative to other ethnic groups.22 With the exception of FAS, research is inconclusive regarding the long-term consequences of maternal substance use on the health and development of children. Children of substance users, however, are much more likely to be displaced
from their home than children of non-users.
41
Charting a Course for the Future of Women’s and Perinatal Health
Interventions
According to Gehshan (1993), the three most common sources of referral of women to substance abuse treatment are: the criminal justice system, family members, and child protective services.23 Only 4 percent of substance abuse programs report medical professionals as the most common source of referral.23 Less than 10 percent of medical schools provide a course on substance
abuse or alcohol addiction.24
Despite the increased focus on interventions for drug abuse, many pregnant women with
drug problems do not receive the help they need. Reasons for not receiving treatment may include
lack of awareness, poverty, lack of available services, and fear of criminal prosecution,25,26 which
may lead addicted women to conceal their drug use from medical providers and further jeopardize
pregnancy outcome.21 Despite increased state funding for and requirements to provide access to services for pregnant women within 24 hours of seeking care, services are still not adequate to meet
the needs of pregnant and parenting women.27
Screening women for substance abuse has not been very common or effective:28 providers
are not adequately educated about women’s substance use. Although no method of screening currently available (maternal reports or biological markers) is optimal, careful questioning of women
about use by caring professionals has been shown to have good sensitivity and specificity,29 and federal agencies are promoting such screening.30 Moreover, with welfare reform and the increasing
numbers of managed care organizations, challenges exist relating to assurance of appropriate
screening and effective care for women with substance abuse problems.31
There are few substance abuse prevention programs for adult women and few empirical
studies conducted specifically on women’s needs. With regard to treatment, components that may
increase the likelihood for successful outcomes in treating pregnant women are child care, transportation, counseling, and parenting education.32 Interventions in the preconception period are very
important as there is a clear link between excessive alcohol abuse in early pregnancy and fetal alcohol syndrome.21
Studies of interventions for women with substance abuse primarily focus on illicit drugs
rather than alcohol. Questions remain about different models of treatment for women with alcohol
dependence, such as family and psychosocial interventions in the community, education regarding
self-esteem, assertiveness training, use of women-only groups, or skills-building and counseling
interventions. Outcomes to gauge success in substance abuse treatment programs need to include
variables other than abstinence from substance use. Studies have shown improvement in women’s
health (including increased psychological functioning and decreased psychiatric symptoms), productivity (including greater employment rates, fewer rearrests, and more appropriate utilization of
public assistance), parenting ability, and the health and well-being of their children.32-34
Many barriers affect women’s access to substance abuse treatment services. These barriers
include lack of early identification by professionals, access to services that accommodate children,
transportation, culturally sensitive services for minority and disadvantaged women, and safe, drugfree housing. Outreach to adult women with no children who are not pregnant nor planning pregnancy is difficult, because these women are less likely to interface with the health care system.
Treatment of women for addiction is also difficult due to complex community, cultural, family, economic, and personal issues,35 as well as women’s fear of being reported to the justice system by
health care providers.25,26 Negative attitudes of staff about the ability of women to recover from their
addiction also are barriers.36 One study noted that Black women experience additional barriers to
treatment related to home responsibilities for children and adult partners, inability to pay, use of
substances to cope with the stresses of social disadvantage, fear of removal of their children, stigma and shame associated with addiction, prior failures in treatment, and waiting lists for services.37
42
Charting a Course for the Future of Women’s and Perinatal Health
A key to preventing and reducing substance abuse among women is decreasing the number of adolescent users. A few programs have been shown to be effective in decreasing marijuana
use for middle to high school-aged children.5 Effective programs include substance abuse education
(with both resistance skills and normative education) in the school health curriculum, as well as parent and community education.38
Effects of Smoking on Women’s and Perinatal Health†
Smoking affects people who actually smoke and many others around them exposed to their
second-hand smoke, including their born and unborn children. Approximately 23 percent of women
smoke,1 but the rates vary by
race, ethnicity, and education
PERCENTAGE OF ADULTS 18 YEARS AND OVER
level. The vast majority of
(AGE ADJUSTED) WHO WERE CURRENT SMOKERS9
smokers begin tobacco use
Year
Female
Male
Total
between the sixth and ninth
grade and few adopt smoking
1974
32.5
42.9
37.2
after age 20.1 Women begin or
1979
30.3
37.2
33.5
continue to smoke as a result of
teenage risk-taking behavior2
1985
28.2
32.1
30.0
and/or peer pressure,3 to lose or
1990
23.1
28.0
25.4
maintain current weight,4-6 to
manage stress,7,8 to combat
1995
22.6
27.0
24.7
depression, and due to addiction to nicotine.
Combatting smoking among women means competing against market forces, including
tobacco advertising and sponsorship of sporting events that target vulnerable groups,10-12 as well as
the fact that tobacco farming remains profitable and important to the economy in certain parts of
the United States.
Consequences
Smoking has been shown to have many deleterious effects on women’s health, including
cancers (lung,4 bladder,4 and cervical13), chronic pulmonary diseases,14 and cardiovascular disease. In
addition, smoking can have secondary effects, including complications of other conditions, such as
hypertension and diabetes. Women who smoke are at increased risk for spontaneous abortion,
bleeding during pregnancy, and having a low birthweight baby.15-18 Women who smoke experience
delayed conception and lower fertility compared to nonsmokers.19 Other health consequences of
smoking include more days of work lost, more visits to the doctor, and greater than average lifetime medical costs than nonsmokers,20 as well as “accelerated aging,” which includes a greater risk
of osteoporosis, early menopause, and skin wrinkling.21 Exposure to environmental (second-hand)
smoke has also been associated with an increased risk of lung cancer, reduced pulmonary function,
asthma, respiratory infections, and cardiovascular diseases.22
Interventions
Primary prevention programs are targeted at children in middle or junior high school, when
smoking often is initiated. These programs tend to have only small effects (about 5 percent) on relative
†
Material adapted from Strobino’s work on smoking in Charting a Course for the Future, Volume II.
43
Charting a Course for the Future of Women’s and Perinatal Health
reduction in smoking rates.23 However, the potential effect of optimal programs is an estimated 1929 percent decrease in smoking.23 Features of optimal programs include implementation early in
the transition to middle school, a same-age peer leader, multi-component strategies, and use of
booster sessions in subsequent
years. Mass media initiatives targeted at adolescent girls have
PREVALENCE OF DAILY CIGARETTE SMOKING*
been shown to reduce smoking
AMONG HIGH SCHOOL SENIORS14
rates when they are coupled
Year
Female
Male
Total
with health education pro24
grams.
1976
28.8
28.0
28.8
1980
23.5
18.5
21.4
Smoking
cessation
treatment is the most common
1984
20.5
16.0
18.7
approach to assisting women to
1988
18.1
17.4
18.1
quit or reduce smoking. In
1996, the Agency for Health
1992
16.7
17.2
17.2
Care Policy Research (in collab1996
21.8
22.2
22.2
oration with the Centers for
Disease Control and Prevention)
*Daily cigarette smokers reported smoking greater than or equal to 1 cigarette per
day during the 30 days before the survey.
published extensive guidelines
for smoking cessation treatment
in clinical practice, and made several conclusions:25
❖
Although brief cessation treatments are effective, there is a dose response relation between
the intensity and duration of treatment and its effectiveness.
❖
The greater the intensity of the program, the more effective it is in producing long-term
abstinence.
❖
Smoking cessation treatment has consistently been found to be cost-effective: costs of cessation programs rise with intensity and duration, but so do cessation rates.
❖
For pregnant women, counseling interventions of at least 10 minutes duration per session
increase quit rates relative to women with no intervention.
❖
Three treatment strategies have been particularly effective: nicotine replacement therapy
using nicotine patches or gum; encouragement and assistance provided by a clinician; and
problem-solving and skills training on techniques to achieve and maintain abstinence.
Smoking cessation programs have not had high quit rates. Eighty to 90 percent of women
and men alike who quit do so on their own, leaving those who smoke more, or who have otherwise been unsuccessful in quitting, in cessation treatment.26 Women participating in smoking cessation programs are more likely to quit when the program incorporates components tailored to their
specific needs, such as weight management,27 stress reduction, treatment for depression, nicotine
gum,27,28 and culturally appropriate approaches.29
Cross-Cutting Issues and Implications
Undergirded by the philosophical, historical, and demographic background, the Charting
a Course initiative’s investigations of specific health issues for women of reproductive age, summarized in this chapter, reveal several broad implications for health programs, policies, and research.
First, while childbearing is an important event for most women, focusing only on women’s health
during pregnancy is far too narrow. Preconception health status affects pregnancy and birth outcomes, and pregnancy itself affects women’s subsequent health status. Moreover, women perform
many roles in their lifetimes and these roles not only affect their health, but their health status also
affects their ability to successfully fulfill these roles, including, but not limited to, parenting.
44
Charting a Course for the Future of Women’s and Perinatal Health
Second, women need comprehensive, integrated programs and services, including preventive services, that address their unique needs and circumstances throughout their lives. This lifespan
perspective recognizes that events that occur earlier in a woman’s life may have a profound effect
on her subsequent health.
Third, health care providers need to receive better training about women’s health issues,
including knowledge about the unique health care needs of women, the differential effects of some
problems — like alcohol abuse — on women relative to men, and the consequences for women of
certain chronic health problems like heart disease, which heretofore have been considered to be
problems primarily among men.
Fourth, social policies must be developed that ensure economic security for women and
continuous access to health care throughout their lives.
Fifth, challenges for improving women’s health research methodology are also apparent
and warrant further attention. More specifically, discipline-specific health research is often narrowly conceptualized such that the joint effects of several risk factors are not simultaneously studied
(e.g., the joint effects of stress, nutrition, poor mental health, and social class on outcomes), nor are
the multiple effects of single exposures examined (e.g., stress events compounded over time may
lead to mental and physical symptoms). In addition, definitions of adverse outcomes used within
various disciplines can be gender biased. For example, initially, the definition of AIDS did not
include the typical symptoms experienced only by women. Similarly, “depression” may be a biased
diagnosis, as many of its symptoms describe characteristics that are more commonly seen among
women in general. Pregnant women, or women with significant likelihood of becoming pregnant,
have historically been excluded from research trials involving drugs. This has resulted in an information gap on how women of reproductive age or pregnant women respond to certain therapeutic regimens.
Finally, the field is challenged with respect to understanding the health services system —
the impacts and interrelationships between medical care and population-based interventions, and
the optimal ways to organize and link health services of various types.
45
46
C
hapter III
Recommendations for
the Future of Women’s and Perinatal Health
Introduction
T
he findings of the literature reviews in the previous chapter reveal a set of recurring
themes in the current state of women’s and perinatal health status and health care in the
United States. First, many challenges are inherent in efforts to ensure quality of care for
women within the context of their lives, including their multiple and complex work and family roles,
the interrelatedness of their social roles and their health status, and the various distinct stages of
health circumstances and events across their lifespans. Second, discontinuities in the health care system — some that affect all people and others that primarily affect women — present problems of
equity, accessibility, coordination, information dissemination, and a lack of focus on prevention.
Third, more attention must be paid to the unique health issues facing women and to the particular
effects of general health and social policies on women. Fourth, enhanced health promotion and
education strategies, taking advantage of some of the new communication technologies, can significantly contribute to improved women’s health status over the long run.
The recommendations that follow were developed by a panel of experts in the field of
women’s and perinatal health (see Appendix for list of experts). Having considered the findings
from the literature summarized in the last chapter, they drew on their experience to identify the
issues most important to pursue over the next decade. These recommendations are by no means
exhaustive; the literature reviews (presented in their entirety in Volume II) offer additional specific
strategies related to their topics, particularly with respect to implications for future research. The
intent of these recommendations is to stimulate action among a broad array of individuals and organizations interested in improving the health of women in this country. The recommendations are
organized according to six domains generic to topics selected for literature review:
❖
Social Policies
❖
Surveillance and Quality Assurance
❖
Service Availability, Coordination, and Organization
❖
Financing of Health Programs and Services
❖
Health Communication and Education Services
❖
Development of Workforce Competency and Capacity
47
Charting a Course for the Future of Women’s and Perinatal Health
The presentation of most sets of recommendations contain several sections: “Context” —
offers background on the topic; “Policy Goals” — lists general aspirations within the domain;
“Strategies” — delineates specific recommendations for policy and program development; “Research
Implications” — highlights a few compelling research questions; and “Potential Constraints and
Opportunities for Action” — offers an appraisal of the challenges and opportunities potentially confronting those who seek to implement the recommendations.
Social Policies
Context
Health care policy evolves within the larger context of social policies that affect women and
their health. Most of the recommendations in this volume focus on specific health system and service interventions for addressing women’s unique health service needs. For women’s and perinatal
health status to markedly improve over the long term, however, certain social and racial inequities
must also be addressed. Although these issues are complex and the recommendations here offered
are broad, the experts involved in this initiative felt they would be remiss if they failed to articulate
the larger changes that must take place in the next century if significant gains in women’s health
are to be made and sustained.
The historical social inequality of women in the United States has meant that women have
been poorer, less well-educated, and less able to assume positions of authority — in politics, the
medical professions, and business — where policy decisions are made. This gender inequity is particularly pronounced for minority and poor women. Because women are under-represented in these
arenas, special attention to gender issues in health and social policy is warranted to ensure greater
equality in the future.
The major demographic shifts taking place — an aging population, a changing ethnic and
racial make-up of the country, and increasing gaps in income — will mean new challenges for both
social and health policy. In addition, the increasing recognition of the environmental influences on
health generally necessitate a closer look at the effects of women’s multiple roles in their family and
work environments. For example, welfare reform places new stresses on women and the health and
social service systems that serve them, even as it may provide opportunities to help women become
economically self-sufficient.
Within the field itself, perinatal health and women’s health advocacy and programs have
evolved independently with different emphases and ideological underpinnings. Sometimes the perspectives of the two groups regarding social policy issues appear to be at odds with one another
— for instance, in regard to incarceration of pregnant women who abuse drugs. Such divergence
in outlooks and interests can threaten the development within the field of a coherent national health
policy agenda for women, thereby diminishing the constituency for promoting the health of women.
Policy Goals
Support policies to improve women’s access to resources that are related to improved health and safe
community environments — including in the realms of higher education, jobs, housing, health care
coverage, pay equity, economic development, child care, domestic violence laws, and gun control.
48
Charting a Course for the Future of Women’s and Perinatal Health
Support processes for developing health policies and health services for women that actively
engage women, encourage them to speak out, and facilitate processes that help women make their
own choices.
Strategies
Develop structures and processes to enhance coordination and collaboration among the diverse
array of constituency groups concerned with women’s and children’s health and well-being. For
example, both women’s and children’s advocacy groups should encourage coordinated plans and
support systems for women and children experiencing abuse. At the federal and state level, policy
and program coordinating committees, with broad representation of constituency groups, should be
convened and given authority and accountability for ensuring integrated women’s and children’s
health policy.
Require federal agencies to prepare formal statements identifying any effects a proposed social policy may have on women’s health and/or access to care. Like environmental impact statements, the
objective would be to prevent avoidable, unintended bad effects. For instance, an impact statement
on the recent welfare reform legislation would have identified inherently inconsistent policies related to (1) out-of-wedlock births/teen pregnancy (in which a family cap was promoted and family
planning services were not), and (2) reducing access to Medicaid-covered health services for immigrant women, particularly prenatal care.
Promote informed decision-making and appropriate legal protections for women to improve access
to health services:
❖
Protect women’s rights to access health information and services and to make health decisions on their own behalf without restrictions on their autonomy — for instance, gag rules
applied to medical/health professionals, spousal permission requirements for reproductive
health services, waiting periods for abortion, and the criminalization of pregnant women’s
behavior in attempts to protect fetuses.
❖
Ensure that female children and adolescents have access to health information and services,
as well as support from parents/guardians, other family members, and health professionals
to make informed health decisions.
Establish safeguards within integrated health systems to protect the privacy of personal health data
from groups such as employers and immigration authorities. Of particular concern are those requirements related to mandatory reporting of domestic violence and other personally sensitive health
issues such as sexually transmitted diseases and psychiatric disorders.
Address the health concerns resulting from changes in the ethnic, cultural, and racial make-up of
the U.S. population:
❖
Promote understanding of, and provide services for, the unique health needs of the many
diverse groups of women; and
❖
Support and extend national initiatives to eliminate disparities in health status among subgroups of women.
Research Implications
Recent social policies (e.g., welfare reform, State Children’s Health Insurance Program) must
be analyzed with respect to impact on women’s access to health care in communities and resulting
health status.
49
Charting a Course for the Future of Women’s and Perinatal Health
Potential Constraints and Opportunities for Action
The very complexity and enormity of these policy issues means that any effective change
would require efforts sustained over many years. In addition, the responsibility for changing these
social policies is diffuse; it is difficult to pinpoint which institutions are accountable and which are
in positions to exert leadership. In the current conservative political and social climate, some health
concerns will be difficult to address, particularly those related to reproductive health and immigration policy. This challenge is coupled with the modest political will exhibited to allocate scarce public resources to these problems.
On the other hand, women have more political strength now than ever before. They vote
in greater numbers. Their greater participation in the workforce has made some changes in social
and health policies economically imperative. And, as women gain leadership positions in government, health care, and business, they wield greater influence in policy.
Surveillance and Quality Assurance
Context
A framework for thinking about quality, as defined by the Institute of Medicine and discussed by others, is one of the most important foundations for considering the future of health care
for women. As evidenced in recent efforts to promote national legislation in this regard, as well as
insurer and provider performance measures and “report cards,” consumers and providers alike
desire quality health care. Quality implies not only that the most appropriate services will be provided for care of health conditions but that the overall goal and impact of the health care system
will be continuous improvements in the health status of the population.
Quality assurance is the process through which the health care industry, government, and
the professional organizations address the need to continuously improve quality. Surveillance is the
process for gathering information about services, outcomes, and health status. Quality must be measurable, but identifying indicators must not be seen as a stumbling block for the establishment of
quality assurance mechanisms.
Inherent in the idea of quality assurance is the concept that there are standards against
which to measure systems of care and practices at any particular facility or for particular conditions.
Such standards must be articulated by official and/or professional bodies. Currently there is no consensus on a definition of quality in women’s health. Moreover, the responsibility for quality assurance has been distributed among a variety of public and private players, which frequently results
in duplicative, overlapping, and/or conflicting standards and guidelines. For example, both national standards established in the form of the Healthy People 2000 and 2010 Objectives and various
clinical standards exist for selected aspects of women’s and perinatal health. This proliferation of
standards can present a burden for responsible providers or agencies. Clarifying the locus of
accountability is essential to achieving quality of health care. As states assume greater roles as insurers, they have greater authority to define quality. Quality requirements can be tied also then to standards for comprehensive care packages.
Other challenges to effective quality assurance also exist. With the increasing private sector involvement in providing services to publicly-insured persons, the role of public health agencies in assuring population-based care has become marginalized. The multiplicity of providers
involved in a woman’s care (due both to women’s utilization patterns as well as shifting provider
networks in managed competition) demands good information flow, but challenges it as well. As
the amount of data collected and shared increases, there is greater need for improved and more
50
Charting a Course for the Future of Women’s and Perinatal Health
efficient mechanisms. The yield from traditional indicators of perinatal health is no longer sufficient
or precise enough to characterize the underlying problems and thereby aid in redirecting program
efforts or resources aimed at improving the health of women.
Strategies
The strategies recommended for surveillance and quality assurance focus on three main areas:
❖
Standards of care — including creating mechanisms and tools for both clients and providers
that promote adherence to and use of standards.
❖
Data-related issues — including developing a conceptual base to direct data collection and
analysis; adopting improved or new indicators for individual, system, and community;
assessing needs/priorities and packaging information in new and useful ways; being judicious in the use of data and using it for program planning/development; and improving
data systems.
❖
Importance of quality assurance functions and leadership — including the necessary attributes of functions and guidelines for this capacity.
Standards/Guidelines Development and Implementation
Develop a “Bright Futures for Women” national guidelines initiative, which would include both
goals for the health status of women as well as for an ideal set of services for women’s health
throughout the lifespan, including pregnancy care. This document should reflect an approach similar to that found in Bright Futures for children (see box) and should (1) incorporate and/or reference existing American College of Obstetricians and Gynecologists’ and American Academy of
Pediatrics’ perinatal guidelines, (2) specifically incorporate health communication and education
components, (3) emphasize coordination of care, and (4) be translated into standards of care for
health professionals/practitioners and practice settings based on a life-stages concept, utilizing both
evidence-based practice and expert opinion findings.
Important activities that should derive from such a document are:
❖
Development of a single, integrated health record for women that includes all aspects of
their care (regardless of provider), specifies recommended well-woman health care, and
allows women themselves to be better-informed health consumers by recording and tracking their own health information.
❖
Development and universal adoption of standardized forms for health history-taking/health
counseling that address the full spectrum of perinatal, reproductive, and non-reproductive
health issues, as well as related psychosocial concerns of women.
Limit proliferation of unnecessary standards that may be contradictory, confusing, or burdensome
to providers or agencies by involving a wide range of stakeholders in their development.
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Charting a Course for the Future of Women’s and Perinatal Health
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents
Bright Futures is a set of practical, comprehensive guidelines published in 1994,
designed to help professionals, families, and communities more effectively promote and
improve the health, education, and well-being of children and adolescents. The document
was prepared through a process of extensive research and consensus development among
four expert panels of multidisciplinary pediatric providers, health care payers, families, and
academicians. The guidance extends beyond the traditional primary focus of clinical practice
standards – physical examination and procedures – to incorporate strategies for health supervision that address contemporary and often especially challenging questions and problems
that children and parents bring to health care visits – learning and behavior, social interactions, nutritional concerns, sexuality, substance use, and other similar issues of child health
and development. Specific steps are outlined for pediatric professionals related to interviews
with patients, developmental challenges, clinical observation of family interactions, and anticipatory guidance for the family, as well as physical assessment and screening procedures.
Bright Futures acknowledges the complex contextual forces that affect physical
health, mental health, cognitive development, and social efficacy and advocates interdisciplinary cooperation in promoting health and preventing disease. The initiative is unique in
that it (1) views health comprehensively, (2) encourages an interactive approach to health
supervision through clinician-family partnerships, (3) recognizes the contextual forces influencing child health, development, and behavior, (4) integrates health concerns and interventions with education and human services, and (5) focuses on the strengths of the child,
family, and community.
Development of Measures/Indicators
Develop conceptual or theoretical frameworks: (1) for understanding the pathways linking demographics, health risks, services received, intermediate outcomes, and health status outcomes specific to women; and (2) to guide collection of relevant data.
Create new indicators of perinatal health that: (1) capture information at the systems, provider, and
client levels; (2) collect information on preconception, prenatal, intrapartum, and postnatal periods
of care; and (3) report these indicators by subgroups of age, race/ethnicity, etc.
Develop a set of measures for assessing community-level need for health and social services and
other resources to support the lives of women (e.g., number of shelter beds to care for abused
and/or homeless women; child care; equal access to recreational facilities.)
Develop performance measures and tools to specifically assess and monitor linkages and coordination with respect to (1) preconception care through postpartum care; (2) interactions among
providers; and (3) physical health care and psychosocial services. These measures should be developed to address coordination at the health plan, service system, individual/client, and population
levels.
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Charting a Course for the Future of Women’s and Perinatal Health
Client Information Systems
Improve the flow of health record information among all providers serving a woman, linking such
elements as preventive and chronic care, and reproductive and non-reproductive care. Safeguards
must be adopted to preserve confidentiality.
Accelerate the development and use of electronic, confidential, unified, longitudinal medical records
for women.
Quality Improvement Mechanisms
Develop a monitoring system to ensure that results of panels of experts convened on topics related to women’s and perinatal heath are integrated into health standards, guidelines, and practices.
Also develop a method to assure that, on a regional or national level, the practice of health professionals complies with recommended medical/health standards and guidelines.
Develop, publish and disseminate an annual national report profiling women’s health status that
includes social indicators (education, etc.), and sub-group analysis (race/ethnicity, etc.) so that policymakers and program administrators are working with the most current information when making decisions.
Establish incentives for states and communities to demonstrate improvements in women’s health status.
Assess unmet health service needs for women on a state-by-state basis by broadening Title V needs
assessment to include such data as women’s health services provided through other programs/agencies (e.g., family planning under Title X, etc.). Use the data to prioritize needs and guide resource
allocation.
Create mechanisms to regularly gather data on consumer preferences for services and about their
experiences receiving services. Use the information to improve health care delivery.
Assure that routinely collected data, such as vital statistics, are analyzed and used for improving
women’s and perinatal health. Public data should be linked and analyzed; relevant information
should be fed back to agencies/stakeholders capable of solving problems and altering health status.
Capacity Building
Develop and establish a locus of accountability for quality assurance systems of surveillance and
reporting population-based data for perinatal care and for women’s health services. Involve all
major stakeholders in this process.
Develop and promulgate guidelines that specify operations, capacity, and standards of practice for
state and local monitoring of women’s and perinatal health. The standards should reflect that data
functions must be timely, useful, theoretically sound, population-based, responsive, flexible, simple,
acceptable, and integrated.
Promote and build local, state, and federal public health agencies’ capacities for leadership in quality assurance and recognize their different skills and roles in the assessment of women’s health. At
the national level, capacity building depends in large part on the collaboration of federal agencies
and their cooperation with the national professional organizations. They can set national policy and
implement surveillance systems nationwide. At the state and local levels, capacity building needs to
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Charting a Course for the Future of Women’s and Perinatal Health
be much more focused on developing expertise in working with the provider community (including managed care) and developing skills in the management of data and information.
Ensure that population-based data continues to be collected, analyzed, and reported, especially as
many public health functions are being privatized.
Potential Constraints and Opportunities for Action
At all levels of health and social policymaking, support for effective performance measurement
and quality assurance has grown in recent years. In addition, public and private health systems are
emphasizing concepts of community accountability, linkages in systems, and multi-factor approaches.
The availability of data is vital to surveillance and quality assurance. The continued underfunding of public health, however, undermines the capacity and credibility of its data and quality
assurance functions. This problem is compounded by both cost and potential conflict of interest disincentives for insurers, health plans, or provider groups to embrace public health functions related
to community-level population health assessment and monitoring. Another challenge is to balance
interest in developing integrated health records for women while assuring privacy, especially given
competition in the health care industry.
A step recommended by experts participating in this initiative is the development of consensus on standards for women’s health — comprehensive “Bright Futures for Women” national
guidelines. Such an initiative might face difficulties in development and promotion, particularly
given the diversity of interests and professions that should be included for a successful process. In
addition, as health care decision-making moves increasingly to the local level, defining and maintaining national standards may prove elusive.
Service Availability, Coordination, and Organization
Context
Women’s and perinatal health must be better integrated. Most women use multiple
providers because obstetrical and gynecological services are usually provided by specialists, which
makes coordinating women’s care particularly challenging. Women’s lives are complicated by their
multiple work and caretaker roles, making convenience an important factor in promoting appropriate utilization of health services, particularly for preventive, non-urgent care. Providing health services in non-traditional settings can improve access, yet care is needed to avoid exacerbating existing problems with poor coordination of services.
Managed care and shifting provider networks threaten what was already a fragile continuity of care for women. Limited choice of providers and demands for women to change providers
compromise the maintenance of comfortable and trusting client/provider relationships and undermine adequate exchange of information about health events and services received. Federal health
programs tend to be developed and managed along narrow and categorical lines; even when health
problems share common etiologies and similar interventions, statutes and funding policies often
require divergent administrative practices or conflicting programming practices. Managed care structures for organizing health services offer opportunities for population-based health in the private
sector, but raise new questions about the loci of responsibility for prevention and other populationbased health services and functions.
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Charting a Course for the Future of Women’s and Perinatal Health
Health care services are not consistently available to all women. The distribution of professional resources is significantly uneven and medical technology continues to be centrally located in cities and teaching institutions. Women living in rural areas often face an inadequate array of
available services or prohibitively high transportation and time costs in accessing needed services.
Moreover, disenfranchised and vulnerable populations — women with disabilities, lesbian women,
incarcerated women, Native-American women — are often left out of the health care system or do
not receive care appropriate to their needs.
Policy Goals
Develop health service models that recognize the holistic nature of women’s health — both biopsychosocially and longitudinally (from pediatric to adult to peri/post menopausal) — and that emphasize health education.
Ensure for every community availability of a full range of high-quality, culturally-competent, coordinated medical care, public health, and other health-related community services addressing health
needs for women of all ages.
Integrate women’s and perinatal health concerns in government programs and public health agencies and among constituency groups. Encourage multidisciplinary and interorganizational collaboration, including coordination of public and private sectors, in relation to all women’s and perinatal health issues.
Encourage creation of integrated models of health care delivery that organize services around the
needs and culturally-based practices of women at all life stages (e.g., comprehensive women’s
health centers, which include primary care services).
Strategies
Support and fund the development and testing of models for delivering health services that are
women-centered and that incorporate a holistic perspective in reproductive, perinatal, and nonreproductive women’s health care. Replicate successful programs for similar populations in communities nationwide — for instance, weight management programs at worksites.
Promote deployment of health professionals and community health workers in ways that support
integrated service delivery, addressing multiple and related health issues simultaneously. For example, restructure categorical health education programs in schools to provide combined smoking,
alcohol, drug, and obesity prevention services.
Support demonstrations that combine health screening and treatment services (e.g., depression,
domestic violence, substance abuse, smoking, family planning) in multiple clinical and non-clinical
settings. Examples of potential opportunities include:
❖
Family planning providers offering referrals to the WIC food program; domestic violence
screening by substance abuse providers.
❖
Educating pediatricians to identify mothers’ health care concerns and needs and to assist
them through screening and referrals.
❖
With more early discharge of mothers and newborns, increased postpartum home visits
offer opportunities to evaluate mothers’ health — postpartum depression, for example.
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Charting a Course for the Future of Women’s and Perinatal Health
Identify collaboration strategies to ensure public health accountability for population-based health
services, such as health education and health screening, in the context of increasing managed care
organizational and financing arrangements.
Focus on the needs of women with health problems and health information deficits that have not been
addressed sufficiently to date — for example, injuries resulting from domestic or sexual violence, mental health and substance abuse treatment, nutrition services for women of high socioeconomic status,
and fitness services for low-income women.
Preserve safety-net services and programs for women — including Title X family planning clinics,
Title V maternal and child health programs, WIC food services, and breast and cervical cancer
screening — and integrate them within comprehensive service delivery systems.
Protect women’s access to sensitive reproductive services, including abortion, adolescent contraceptive services, and STD/HIV screening and treatment, in their communities.
Make health care services easier for women to access for themselves and their family members by
offering, for example, convenient locations and hours of operation, subsidized transportation, onsite child care, community outreach workers, translator/interpretation services, and gender- and
culturally-competent providers and programs.
Ensure community-level outreach to bring high-risk and underserved groups of women (whether
high- or low-income, urban or rural) into the health care system.
Establish, test, and apply a range of strategies to monitor and enhance coordination of women’s health
services, particularly high-risk perinatal care with mental health, substance abuse, and “wrap-around”
health-related services. This is particularly important in the current managed care environment, which
is characterized by shifting and often disconnected networks of providers. For instance, in many private health plans, mental health and substance abuse services are provided by separate entities.
Ensure that screening services are implemented to the fullest extent. Publicly-funded screening programs must provide adequate linkages to treatment and social services. For example, substance
abuse treatment slots must be available for those identified as needing services through screening.
HEDIS, the national standards developed by the managed care industry, could enhance its measures
related to referrals and follow-up of hard-to-access services.
Decrease federal and state level administrative complexities stemming from the categorical structure
of public programs — including overregulation, separate funding streams, and categorical eligibility. For example, eligibility requirements for federally funded family planning, sexually transmitted
disease, prenatal, and maternity-specific nutrition services could be made entirely consistent and
enrollment in the program(s) a single event.
Using infant mortality reviews as a model (in which diverse professionals and community members are
brought together to understand the reasons behind a child’s death), promote review processes as a
strategy for improving the coordination of services at the community, state, and federal levels for breast
and cervical cancer, domestic violence, perinatal substance abuse, chronic illness, and child welfare.
Research Implications
Studies are needed to document the health benefits and costs of coordination and the consequences and costs of lack of coordination — for instance, the potential negative outcomes related to the disintegration of regional systems of perinatal care.
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Charting a Course for the Future of Women’s and Perinatal Health
Despite the massive changes underway in our health care system, little is known about how
new organizational forms, such as comprehensive, primary care women’s health centers and the various types of managed care organizations (including mental health and substance abuse “carve
outs”) are affecting women’s health care. Research needs, therefore, involve addressing how
women’s health care utilization and quality differ by provider type and by organizational context.
Research is needed to determine how receiving care from different types of primary care providers
affects the quality of care; how the coordination of reproductive and non-reproductive care in different types of organizations impacts on outcomes; and how the physician-patient communication
process in different types of settings affects satisfaction and other outcomes.
Potential Constraints and Opportunities for Action
In part because efforts to increase availability and coordination of services have largely
been insufficient in the past, the effectiveness of coordination has not been well-documented. Wellcoordinated services require partnerships that are labor- and time-intensive and, therefore, expensive on their face. Competition in the new health care marketplace may undermine efforts at both
the individual and systems levels to implement partnerships that are necessary for coordination of
care; this is a particular challenge for providers of safety net services. In a system of many public
and private providers, accountability for coordination activities is unclear. Moreover, while advances
in communications technology promise great potential for remedying coordination challenges —
particularly in rural areas — privacy concerns complicate questions of the information-sharing necessary for sufficient coordination of care. Finally, issues remain related to the adequacy of health
professional training with respect to coordination of care (see section on Development of Workforce
Competency and Capacity).
Financing of Health Programs and Services
Context
Lack of health insurance coverage continues to be a problem for many women. In addition,
recent legislation impacting public insurance programs (for instance, in the Personal Responsibility
and Work Opportunity Reconciliation Act of 1996) created new barriers to enrollment and eligibility. Public health policy for women under the age of 65 has emphasized insuring them primarily
when they are pregnant, which limits receipt of preconception care, such as family planning and
nutrition counseling. Even recent legislative efforts to remediate problems associated with access to
insurance — such as the Health Insurance Portability and Accountability Act of 1996 and the Mental
Health Parity Act of 1996 — are thwarted by industry challenges to their full implementation. Further
complicating such matters are managed care cost-containment strategies that may create disincentives for providing screening and treatment services needed by women and may limit the amount
of time providers are able to spend with women on health education and counseling and other preventive services. Even when primary prevention may prove to be more cost-effective in the long
run, it remains poorly funded in both the public and private sectors.
In addition, privatization of publicly-funded health services through Medicaid managed care
waivers is reducing local health departments’ ability to provide direct safety net services and is
threatening the funding base for core public health functions. Finally, categorical funding in the
public sector continues to impede efforts aimed at coordinated women’s health care.
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Charting a Course for the Future of Women’s and Perinatal Health
Policy Goals
Support the long-term goal of affordable universal health insurance for all persons.
Increase the reach of population-based health services and maintain public health functions in the
face of further privatization of publicly-funded health services.
Strategies
Encourage all health plans — both private and public — to provide comprehensive benefits packages consistent with the recommended “Bright Futures for Women” national guidelines covering
reproductive and non-reproductive services for women across the lifespan.
Ensure women’s continuity of health insurance coverage and access to affordable health care
providers: (1) despite changes in employment, marital status, pregnancy status, or other factors; (2)
despite loss of Medicaid eligibility for any reason; and (3) for all legal and illegal immigrant women,
irrespective of pregnancy status.
Promote complete implementation of federal statutes requiring parity in coverage for mental health
and substance abuse services.
Promote increases in funding for public health population services and infrastructure functions.
Promote regionalization of perinatal care through cost-sharing and risk-adjusted reimbursement
between basic (Level I), specialty (Level II), and subspecialty (Level III) facilities or services.
Mandate a specific communication and education set-aside within all U.S. Department of Health and
Human Services-funded women’s and perinatal health service programs to ensure that health promotion is an integral part of all efforts to improve women’s health.
Potential Constraints and Opportunities for Action
The financing of health care is influenced by the political environment. Lack of political will
for “unpopular” populations, such as immigrants and welfare recipients, makes it difficult to increase
health care spending. Employers are the major purchasers of health care coverage. Many are hesitant to expand benefits packages as it becomes increasingly difficult for them to cover rising health
care costs and either break even or turn a profit. Many employers therefore have begun limiting
health care benefits offered for dependents of their employees.
Recent national legislation, such as the State Children’s Health Insurance Program (1997),
and the Health Insurance Portability and Accountability Act, has the potential to expand the number of people who have health insurance coverage that is comprehensive and continuous. The
momentum from these expansions can be used to propel educational and lobbying efforts to extend
insurance coverage for uninsured and underinsured populations. Educational endeavors should
include information illustrating the economic and societal contributions that traditionally uninsured
populations — such as immigrants — make in the United States. It may be possible to weave arguments in favor of providing comprehensive health care coverage to all residents into current proposals to reform Medicare and managed care.
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Charting a Course for the Future of Women’s and Perinatal Health
Health Communication and Education Services
Context
Chronic illnesses, including heart and lung disease, that take a heavy human and financial
toll in the last third of women’s lives have their genesis in behaviors that begin in late childhood
and early adolescence. Because never adopting many habits detrimental to health — like smoking
or heavy drinking — is easier than quitting or modifying a harmful behavior, health communication
and education services targeted to young girls and adolescent women can prevent many health
problems later in life — for themselves and for their offspring. The challenge, however, is to make
the benefits of healthy behavior immediately relevant to girls and young women (as well as adult
women), because health education is not very effective in prompting behavior change when the
potential benefits seem distant or irrelevant. Unfortunately, too, health care providers are sometimes
poor health educators, often because of inadequate training. Because evaluation research on health
education interventions is neither well-funded nor well-developed, identifying the best strategies
and practices remains difficult.
Health education efforts can capitalize on the current cultural emphasis on personal responsibility when promoting the benefits of self-care — including proper nutrition, smoking abstinence,
responsible alcohol consumption, adequate rest, stress-reducing exercise regimens, and responsible
sexual relationships. The tremendous advances in information technology, including the Internet,
offer new opportunities to health educators. However, because the wealth of information available
to consumers is of such variable quality, it is more important than ever to teach women, particularly young women, how to assess critically the information they receive.
Pregnancy planning, pregnancy care, and pediatric care present important opportunities to
promote positive health habits with women. In addition, in the face of changing racial, ethnic, and
cultural demographics in the United States, health care professionals must pay special attention to
the diverse needs of various sub-populations and be able to communicate in the target audiences’
languages.
Policy Goal
Design and implement age-appropriate, culturally and linguistically appropriate health education
strategies that improve women’s ability to make informed health-related choices for themselves, to
adopt positive health behaviors, and to navigate effectively the health care system.
Strategies
Focus health communication and education strategies on the following specific knowledge and skill
areas:
❖
Healthy body images and approaches to maintaining health.
❖
Critical thinking skills to increase the ability to analyze and critique advertising and other
media messages.
❖
Competence in personal health maintenance.
❖
Effective strategies for communicating with health care providers.
❖
Age-appropriate health screening and health education topics — e.g., pap tests for women
18 years and older and sexually active adolescents, osteoporosis information for all women.
❖
Reduction of behaviors detrimental to health — e.g., smoking.
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Charting a Course for the Future of Women’s and Perinatal Health
Design health communication and education strategies that incorporate an understanding of the
multiple demands on, and complex roles of, women:
❖
Use communication methods and education messages that are designed to meet the needs
of segmented audiences of women, particularly high-risk groups.
❖
Use competent communication professionals and proven marketing techniques to communicate positive health messages to women that promote healthy behavior.
❖
Promote health education in places that women frequent, e.g., grocery stores, schools, community organizations, churches, adult education programs, and work sites. Use community-based strategies like outreach workers and educators recruited from the community and
linkages to local service providers.
❖
Use clinical health visits for teaching health promotion; capitalize on “teachable moments.”
❖
Encourage large private sector companies to develop and implement programs, in collaboration with local organizations, that promote exercise among women of all ages, races, and
ethnicities.
❖
Use multiple media approaches, capitalizing on the most appropriate media for specific
populations — for instance, the Internet for college students, radio for young adolescents,
and billboards on buses and taxis in cities. Use the entertainment industry — concerts, soap
operas, sporting events, and popular television programs — to reach women with messages
about promoting healthy body images, attitudes, and behaviors.
❖
Establish a Media Advisory Committee at the U.S. Department of Health and Human
Services to encourage the use of prominent sports and entertainment personalities in promoting healthy behaviors in women.
Implement strategies for community partnerships and collaboration in health communication and
education:
❖
Promote incentives for public sector/health plan partnerships to implement health education strategies (including through school-based health clinic operations).
❖
Develop approaches for information-sharing among health care professionals providing services to women to promote consistent health education messages.
❖
Involve consumer and community groups in the design and implementation of health education and information programs.
❖
Assure that health promotion messages are integrated with services in the community that
address the needs of specific populations — for instance, a media campaign promoting
breast cancer self-examinations should be coordinated with women’s health care providers
in the community.
Research Implications
Rigorous research should be promoted and funded to identify the most effective communication and education practices for women’s and perinatal health. At the population level, the use
of the mass media should be examined. At the individual level, studies are needed to identify effective models for clinician/patient communication that improve clinicians’ ability to identify women’s
needs and address potential barriers to women’s adherence to therapeutic regimens.
Potential Constraints and Opportunities for Action
The effectiveness of health communication and education strategies has not been well-documented. This gap in our knowledge base is related in part to measurement challenges, including the
long time-frame necessary for observing impact on behavior. Health promotion must compete within a marketplace that offers messages that contradict sound health practices. Even with media industry cooperation, it can be difficult to “control the message,” which raises concerns about quality of
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Charting a Course for the Future of Women’s and Perinatal Health
information people receive. In addition, American society has a longstanding cultural aversion to public discourse on issues related to sexuality, which complicates public health efforts to educate women
about such issues as pregnancy planning, sexually transmitted diseases, lesbian health, domestic violence, and attitudes about breastfeeding, among others.
Consumers are seeking useful information about improving their health. New media technologies offer expanded routes to transmit health promotion messages. The Healthy People 2010
Objectives could provide a framework for designing health education efforts, an opportunity for
common ground among stakeholders, and a way to focus the public’s and providers’ attention.
Development of Workforce Competency and Capacity
Context
Perhaps the most important attribute of an effective health care delivery system is a competent and committed workforce — both clinical and non-clinical professionals and lay providers.
As the literature reviewed in the previous chapter shows, a wealth of new research-based information related to women’s health is available, but it must be better translated into practice. Moreover,
new information technologies offer cost-effective opportunities to provide on-going training to
health care providers.
The health care workforce is made up of a wide array of professional and lay providers,
including community health workers, physician’s assistants, nurses, doctors, and others. Two main
issues arise when considering women and the health workforce serving them: (1) the level of
knowledge and sensitivity of the health workforce to women’s health issues; and (2) the number
and representation in leadership of women in the health workforce.
Because women comprise the largest group of consumers of health care and make the
majority of health-related decisions for their families, it is critical that the health care workforce
receive training related to understanding their health care needs and practices. This understanding
needs to reflect the growing racial, ethnic, and cultural diversity of women in the United States.
Policy Goal
Encourage girls’ interest in the health professions earlier in the education process, and provide support and resources to make successful participation of women in the health professions field feasible.
Strategies
Understand and promote diversity (gender/racial/ethnic/cultural) in the health workforce. Specific
strategies should:
❖
Promote more training of women to care for women.
❖
Address the cost of education as a barrier to pursuing health profession careers, particularly
among low-income groups and minority populations, by offering such support as low-cost
loan programs.
❖
Reconsider bolstering affirmative action to increase minority representation among
providers.
❖
Enhance science and math education starting in grade school to increase the applicant pool
of girls, particularly those from low-income populations.
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Charting a Course for the Future of Women’s and Perinatal Health
Promote women as leaders within all health professions by providing resources for women’s health
leadership fellowships and mentorships and for women’s participation in health policy and management educational programs. The Association of American Medical Colleges (AAMC), for example, has
developed an initiative called “Increasing Women’s Leadership in Academic Medicine,” which seeks
to increase the presence of women medical faculty through a series of fifteen recommendations to
leaders of medical schools, teaching hospitals, academic medical societies, and the AAMC.
Provide training for women’s health providers that encompasses the concepts and content included in “Bright Futures for Women” national guidelines proposed in these recommendations:
❖
Promote understanding of gender-specific issues and gender differences related to clinical
care and psychosocial issues, as well as other needed non-health services like child care.
❖
Encourage provider training in the full range of health care needs of women. Implement
women’s health curricula as a component of core education requirements.
❖
Provide training to a wide range of professionals, practitioners, and clinicians on collaborative delivery of health care services for women that ensures coordinated and continuous
care across reproductive and non-reproductive health services and for women using multiple providers (especially those with chronic illness or disability).
❖
Provide training for clinicians in population-based health sciences, evidence-based practice,
and collaborative service delivery. For example, as non-surgical treatments and outpatient
therapies become more routine, the traditionally surgery-oriented specialties, such as obstetrics/gynecology, must ensure consistent core training in primary care and ambulatory-based
medicine, rather than subspecialty, hospital-based care.
Educate established and new providers regarding cultural competence and sensitivity:
❖
Develop and implement core competencies for accreditation of training programs.
❖
Establish and promote role models.
❖
Enhance communication skills.
❖
Encourage education of bilingual and multi-lingual clinicians.
Improve the capacity of providers to coordinate women’s and perinatal services across specific
health issues and across the continuum of perinatal and non-reproductive health care:
❖
Cross-train health professionals to address the broad range of women-specific health concerns and the interactions among them in order to provide appropriate screening, counseling, referral, and treatment services.
❖
Reassess current licensing statutes and credentialing practices that unnecessarily limit the
scope of practice of health practitioners (nurses, social workers, etc.) and promote appropriate expansions that contribute to improved coordination of service provision to women.
❖
Encourage educational institutions to expose health professional students to strategies for
coordinating direct patient care.
❖
Develop and maintain a repository of evaluated best practices in clinical care coordination/case management.
❖
Promote information-sharing and communication among providers/clinicians by (1) encouraging federal health agencies to involve the broad spectrum of health professions in the
development of policy and programs and in making sure that the materials they disseminate
reach all relevant groups; (2) establishing liaisons between health care providers in communities and perinatal specialists to provide consultation for high-risk patients; (3) developing a
standard format for computerized patient records that can be used nationally and easily
adopted to various clinical settings; and (4) supporting and funding the use of computerized
data collection for individualized patient care and population data collection and analysis.
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Charting a Course for the Future of Women’s and Perinatal Health
Improve providers’ communication skills:
❖
Teach health care providers to effectively communicate health promotion messages to
women, appropriate to their cultural and educational backgrounds.
❖
Teach public health practitioners and academicians how to use the news media to disseminate accurate information about women’s and newborns’ health issues.
❖
Disseminate best practices in the effective communication of health education messages for
women’s and perinatal health at the policy, population-based, and personal health levels.
Develop new funding streams for initiating and sustaining activities in women’s reproductive/nonreproductive health services research and education — in particular:
❖
Health professionals education/training/re-training in academic health centers.
❖
Basic science research.
❖
Research programs in community agencies (including public health programs) providing
services for women.
❖
Partnerships between academic health centers and community-based organizations.
❖
Practice-based clinical research.
For example, medical “trust funds” — made up of contributions from public payers (Medicaid,
Medicare) and private insurers — could be a possible new source of revenue to sustain academic
training centers.
Research Implications
Improvements are needed in the science of forecasting demand and supply for health
care providers in general and in specific geographic areas (e.g., urban vs. rural). New models to
estimate provider supply and demand will need to adjust for the potential changing role of
obstetrician-gynecologists in providing women’s health care and for the emerging role of nonphysician providers, such as nurse midwives and physician’s assistants in providing care.
Potential Constraints and Opportunities for Action
These efforts in workforce development must contend with a recent trend of funding cutbacks for health professional education and for incentives to recruit minority candidates in particular. Advocacy for a more diverse group of providers is complicated by the lack of clear documentation that workforce diversity makes a difference in terms of health outcomes. Finally, education
programs for health professionals can be resistant to challenges to the status quo and its traditions
— particularly in the medical professions. On the other hand, this time of intense change in the
health care system may offer opportunities to introduce new ideas and practices into service delivery and provider education.
63
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Charting a Course for the Future of Women’s and Perinatal Health
Appendix
Participants: Charting a Course for the Future Meeting of Experts, April 1998
Maribeth Badura, MSN, RN
Chief, Program Operations Branch
Division of Healthy Start
Maternal and Child Health Bureau
Health Resources and Services Administration
Department of Health and Human Services
Donna M. Barber, RN, MPH
Director, Division of Family Health Services
Florida Department of Health
Doris Barnette, ACSW
Principal Advisor to the Administrator
Health Resources and Services Administration
Department of Health and Human Services
Barbara A. Bartman, MD, MPH
Assistant Professor of Medicine, General Medicine
University of Maryland Medical Center
Claire Brindis, DrPH
Director, Center for Reproductive Health and Policy Research
Institute for Health Policy Studies
University of California, San Francisco
Yvonne Bronner, ScD, RD, LD
Assistant Professor, Department of Population and Family Health Sciences*
Johns Hopkins School of Public Health
Charlyn Cassady, PhD
Research Associate, Department of Population and Family Health Sciences*
Johns Hopkins School of Public Health
65
Charting a Course for the Future of Women’s and Perinatal Health
Charlotte Catz, MD
Chief, Pregnancy and Perinatology Branch
National Institute of Child Health and Human Development
Department of Health and Human Services
Janet Chapin, RN, MPH
Associate Director, Division of Women’s Health Issues
American College of Obstetricians and Gynecologists
Alice J. Dan, PhD
Director, Center for Research on Women and Gender
Chicago, Illinois
Catherine Ehlen, MA
Research Associate, Medical Affairs
American Association of Health Plans
Norma Finkelstein, MSW, PhD
Director, Coalition on Addiction, Pregnancy and Parenting, Inc.
Cambridge, Massachusetts
Loretta P. Finnegan, MD
Special Advisor to the Director
Center for Substance Abuse Treatment
Department of Health and Human Services
Sally Fogerty, BSN, MEd
Deputy Director
Bureau of Family and Community Health
Massachusetts Department of Public Health
David Gagnon, MPH
President, National Perinatal Information Center
Providence, Rhode Island
Representing the Secretary’s Advisory Committee on Infant Mortality
Rita Goodman, RNC, MS
Chief Nurse, Division of Community and Migrant Health
Bureau of Primary Health Care
Health Resources and Services Administration
Department of Health and Human Services
Barbara R. Gottlieb, MD, MPH
Assistant Professor, Department of Maternal and Child Health
Harvard University School of Public Health
Holly Allen Grason, MA
Associate Scientist, Department of Population and Family Health Sciences*
Director, Women’s and Children’s Health Policy Center
Johns Hopkins School of Public Health
66
Charting a Course for the Future of Women’s and Perinatal Health
Maureen Greer
Assistant Deputy Director, Bureau of Child Development
Part C Coordinator, Indiana Family and Social Services Administration
Representing the National Perinatal Association
Joy Grohar, RNC, MS, CNM
President, Comprehensive Perinatal Consultants
Lockport, Illinois
Marcy Gross
Director, Women’s Health
Agency for Health Care Policy and Research
Department of Health and Human Services
Bernard Guyer, MD, MPH
Professor and Chair, Department of Population and Family Health Sciences*
Johns Hopkins School of Public Health
Betty Hambleton, BS
Senior Advisor for Women’s Health
Health Resources and Services Administration
Department of Health and Human Services
Catherine A. Hess, MSW
Executive Director
Association of Maternal and Child Health Programs
Heddy Hubbard, RN, MPH
Health Scientist Administrator
Agency for Health Care Policy and Research
Department of Health and Human Services
Ellen Hutchins, ScD, MSW
Health Care Administrator
Division of Healthy Start
Maternal and Child Health Bureau
Health Resources and Services Administration
Department of Health and Human Services
Donna Hutten, MS, RN
Chief, Program Development and Coordination Branch
Division of Healthy Start
Maternal and Child Health Bureau
Health Resources and Services Administration
Department of Health and Human Services
Bonnie Connors Jellen, MHSA
Director, Section for Maternal and Child Health
American Hospital Association
67
Charting a Course for the Future of Women’s and Perinatal Health
Lisa Kaeser, JD
Senior Public Policy Associate
The Alan Guttmacher Institute
Laurie A. Konsella, MPA
Regional Women’s Health Coordinator
Region VIII, Public Health Service
Department of Health and Human Services
Ann M. Koontz, CNM, DrPH
Associate Director for Perinatal Policy
Division of Healthy Start
Maternal and Child Health Bureau
Health Resources and Services Administration
Department of Health and Human Services
Carol C. Korenbrot, PhD
Associate Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences
Institute for Health Policy Studies
University of California, San Francisco
Milton Kotelchuck, PhD, MPH
Professor, Department of Maternal and Child Health
School of Public Health
University of North Carolina at Chapel Hill
Joan M. Leiman, PhD
Executive Director
Commission on Women’s Health
The Commonwealth Fund
Tamara Lewis-Johnson, MBA, MPH
Senior Public Health Advisor
Office of Minority and Women’s Health
Bureau of Primary Health Care
Health Resources and Services Administration
Department of Health and Human Services
Susan M. Lieberman, MS
Director, Office of Maternal and Child Health
Philadelphia Department of Public Health
George A. Little, MD
Professor of Pediatrics, Obstetrics and Gynecology
Dartmouth-Hitchcock Medical Center
68
Charting a Course for the Future of Women’s and Perinatal Health
Thurma McCann Goldman, MD, MPH
Director
Division of Healthy Start
Maternal and Child Health Bureau
Health Resources and Services Administration
Department of Health and Human Services
Cynthia Minkovitz, MD, MPP
Assistant Professor, Department of Population and Family Health Sciences*
Johns Hopkins School of Public Health
Dawn Misra, PhD
Assistant Professor, Department of Population and Family Health Sciences*
Johns Hopkins School of Public Health
Claudia Morris, MPH
Deputy Director
National Healthy Mothers, Healthy Babies Coalition
Wanda Nicholson, MD, MPH
Assistant Professor, Departent of Obstetrics and Gynecology
Assistant Professor, Department of Epidemiology/Preventive Medicine
University of Maryland
Audrey H. Nora, MD, MPH
Associate Administrator for Maternal and Child Health
Maternal and Child Health Bureau
Health Resources and Services Administration
Department of Health and Human Services
Judy Norsigian
Program Director
Boston Women’s Health Book Collective
Women’s Health Information Center
Patricia O’Campo, PhD
Associate Professor, Department of Population and Family Health Sciences*
Johns Hopkins School of Public Health
Melissa Perry, ScD
Visiting Scientist, Occupational Health Program
Harvard University School of Public Health
Phyllis T. Piotrow, PhD
Professor, Department of Population Dynamics
Director, Center for Communication Programs
Johns Hopkins School of Public Health
69
Charting a Course for the Future of Women’s and Perinatal Health
Carolina Reyes, MD
Assistant Professor
George Washington University Medical Center
Representing National Coalition of Hispanic Health and Human Services Organizations
Helen Rodriguez-Trias, MD
Co-Director, Pacific Institute for Women’s Health
Public Health Institute
Marjory Ruderman, MHS
Project Director, Women’s and Children’s Health Policy Center
Johns Hopkins School of Public Health
Sheryl Burt Ruzek, PhD, MPH
Professor, Department of Health Studies
Temple University
William Sappenfield, MD, MPH
Assistant Professor, University of Nebraska Medical Center
MCH Epidemiologist, CityMatCH
Representing CityMatCH
Richard H. Schwarz, MD
Department of Obstetrics and Gynecology
New York Methodist Hospital
Gillian B. Silver, MPH
Research Assistant, Women’s and Children’s Health Policy Center
Johns Hopkins School of Public Health
Deborah M. Smith, MD, MPH
Assistant Professor of Obstetrics and Gynecology, Howard University College of Medicine
Representing the American College of Obstetricians and Gynecologists
Phillip Smith, MD
MCH Coordinator
Indian Health Service
Department of Health and Human Services
Terrence Smith, MD, MPH
Chief, Perinatal Care Section
California State Department of Health Services
Beverly Stauffer, RN, MS
Health Officer/Director
Pottawatomie County Health Department
Westmoreland, Kansas
Representing the National Association of County and City Health Officials
70
Charting a Course for the Future of Women’s and Perinatal Health
Donna Strobino, PhD
Professor, Department of Population and Family Health Sciences*
Johns Hopkins School of Public Health
Carol S. Weisman, PhD
Professor, Department of Health Management and Policy
University of Michigan School of Public Health
Lynne Wilcox, MD, MPH
Director, Division of Reproductive Health
Centers for Disease Control and Prevention
Department of Health and Human Services
Carol W. Williams, DSW
Associate Commissioner for the Children’s Bureau
Administration on Children, Youth and Families
Department of Health and Human Services
Deanne Williams, CNM, MS
Executive Director
American College of Nurse-Midwives
Gail J. H. Wilson, MS, MPH
Director, Chicago Healthy Steps for Young Children
Advocate Health Care
Susan F. Wood, PhD
Assistant Director for Policy
Office on Women’s Health
Department of Health and Human Services
*Subsequent to the April 1998 meeting, the Johns Hopkins School of Public Health Department of
Maternal and Child Health was renamed the Department of Population and Family Health Sciences.
71
72
Charting a Course for the Future of Women’s and Perinatal Health
References
Chapter I: Toward A New Vision of Women’s Health
1.
Smith-Rosenberg C, Rosenberg C, 1984. The female animal: Medical and biological views of woman and her role in nineteenth-century America. In Leavitt J, ed. Women and Health in America. Madison, WI: University of Wisconsin Press.
2.
Skocpol T, 1995. Social Policy in the United States: Future Possibilities in Historical Perspective. Princeton, NJ: Princeton
University Press.
3.
Gordon L, 1990. Woman’s Body, Woman’s Right: Birth Control in America. New York: Penguin.
4.
Rothman S, 1978. Women’s Proper Place: A History of Changing Ideals and Practices, 1870 to the Present. New York:
Basic Books.
5.
Speert H, 1980. Obstetrics and Gynecology in America: A History. Chicago: American College of Obstetricians and
Gynecologists.
6.
Meckel R, 1990. Save the Babies: American Public Health Reform and the Prevention of Infant Mortality, 1850-1929.
Baltimore, MD: Johns Hopkins University Press.
7.
Burt M, 1993. Publicly Supported Family Planning in the United States: Legislative and Policy History Implications for
the 1990s. Washington, DC: The Urban Institute.
8.
Ku L, 1993. Financing of family planning services. Washington, DC: The Urban Institute and Child Trends, Inc.
9.
Ruzek S, 1978. The Women’s Health Movement: Feminist Alternatives to Medical Control. New York: Praeger.
10.
Council on Graduate Medical Education, 1995. Fifth Report: Women & Medicine. Washington, DC: Health Resources
and Services Administration.
11.
American Medical Association, 1997. Physician characteristics and distribution in the United States, 1996/97. Chicago,
IL: American Medical Association.
12.
Weisman C, 1998. Women’s Health Care: Activist Traditions and Institutional Change. Baltimore, MD: The Johns
Hopkins University Press.
13.
National Center for Health Statistics, 1998. Health, United States, 1998 with Socioeconomic Status and Health
Chartbook. Hyattsville, MD: NCHS.
14.
Bureau of the Census, 1996. Resident Population of the United States: Middle Series Projections, 2006-2010, by Age and Sex,
[ONLINE]. Available: http://www.census.gov/population/projections/nation/nas/npas0610.txt.
15.
Campbell P, 1995. Population Projections: States, 1995-2025, [ONLINE]. Available: http://www.census.gov/prod/2/pop/
p25/p25-1131.pdf.
16.
Day JC, 1995. National Population Projections, [ONLINE]. Available: http://www.census.gov/population/pop-profile/p23-189.pdf.
17.
Horton J, 1995. The Women’s Health Data Book: A Profile of Women’s Health in the United States. Washington DC:
Jacobs Institute of Women’s Health.
18.
Day J, Curry A, 1998. Educational Attainment in the United States: March 1997. U.S. Census Bureau. Current Population
Reports, [ONLINE]. Available: http://www.census.gov/prod/3/98pubs/p20-505.pdf.
19.
Wagener DK, Walstedt J, Jenkins L, Burnett C, Lalich N, Fingerhut M, 1997. Women: Work and health. Vital and Health
Statistics 3(31): 1-16.
20.
Bureau of the Census, 1997. Money Income in the United States: 1996 (With Separate Data on Valuation of Noncash
Benefits), [ONLINE]. Available: http://www.census.gov/prod/3/97pubs/p60-197.pdf.
73
Charting a Course for the Future of Women’s and Perinatal Health
21.
Maternal and Child Health Bureau, 1998. Child Health USA, 1996-1997. Washington, DC: U.S. Department of Health
and Human Services.
22.
Bureau of Labor Statistics, 1998. Employment Characteristics of Families in 1997, [ONLINE]. Available:
ftp://146.142.4.23/pub/news.release/History/famee.052198.news.
23.
National Center for Health Statistics, 1998. Births, marriages, divorces and deaths for 1997. Monthly Vital Statistics
Report 46(12).
24.
Ventura SJ, Peters KD, Martin JA, Maurer JD, 1997. Births and deaths: United States, 1996. Monthly Vital Statistics
Report 46(1): 1-41.
25.
Abma JC, Chandra A, Mosher WD, 1997. Fertility, family planning, and women’s health: New data from the 1995
National Survey of Family Growth. Vital Health Statistics 23(19): 1-28.
26.
Saluter AF, 1996. Marital Status and Living
http://blue.census.gov/prod/1/pop/p20-484.pdf.
27.
National Center for Health Statistics, 1997. Vital Statistics Report, 7/97. Births, Marriages, Divorces, and Deaths for
1996, [ONLINE]. Available: http://www.cdc.gov/nchswww/data/mvs45_12.pdf.
28.
Bureau of the Census, 1995. Women in the
http://www.census.gov/apsd/www/statbrief/sb95_19.pdf.
Profile,
[ONLINE].
Available:
29.
Bureau of the Census, 1998. Money Income in the United States: 1997,
http://www.census.gov/prod/3/98pubs/p60-200.pdf.
[ONLINE].
Available:
30.
Bureau of the Census, 1995. Who receives child support? Statistical Brief 95(16): 1-2.
31.
Ross C, Mirowsky J, 1995. Does employment affect health? Journal of Health and Social Behavior 36: 230-243.
32.
Pugliesi K, 1995. Work and well being: Gender differences in the psychological consequences of employment. Journal
of Health and Social Behavior 36(1): 57-71.
33.
Verbrugge LM, 1985. Gender and health: An update on hyposthesis and evidence. Journal of Health and Social
Behavior 26: 156-182.
34.
Brett KM, Strogatz DS, Savitz DA, 1997. Employment, job strain, and preterm delivery among women in North Carolina.
American Journal of Public Health 87(2): 199-204.
35.
Ettner SL, 1995. The impact of “parent care” on female labor supply decisions. Demography 32(1): 63-80.
36.
Boaz RF, 1996. Full-time employment and informal caregiving in the 1980s. Medical Care 34(6): 524-536.
Arrangements:
United
March
States:
A
1994,
[ONLINE].
Available:
Chapter II: Key Topics in Women’s and Perinatal Health: Findings from
the Literature
Health Care Services and Systems for Women of Reproductive Age
1.
Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, 1996. Primary Care: America’s Health in a New Era. Washington,
DC: National Academy Press.
2.
Starfield B, 1992. Primary Care: Concept, Evaluation, and Policy. New York, NY: Oxford University Press.
74
Charting a Course for the Future of Women’s and Perinatal Health
3.
Horton J, 1995. The Women’s Health Data Book: A Profile of Women’s Health in the United States. Washington DC:
Jacobs Institute of Women’s Health.
4.
Weisman CS, 1996. Women’s use of health care. In Falik MM, Collins KS, eds. Women’s Health: The Commonwealth
Fund Survey. Baltimore, MD: Johns Hopkins University Press, 19-48.
5.
Weisman CS, Cassard SD, Plichta SB, 1995. Types of physicians used by women for regular health care: Implications
for services received. Journal of Women’s Health 4: 407-416.
6.
Wyn R, Brown ER, Yu H, 1996. Women’s use of preventive health services. In Falik MM, Collins KS, eds. Women’s
Health: The Commonwealth Fund Survey. Baltimore, MD: Johns Hopkins University Press, 49-75.
7.
National Center for Health Statistics, 1995. Health, United States, 1994. Hyattsville, MD: U.S. Public Health Service.
8.
American Academy of Nursing, 1997. Women’s health and women’s health care: Recommendations of the 1996 AAN
Expert Panel on Women’s Health. Nursing Outlook 45: 7-15.
9.
Gabay M, Wolfe SM, 1997. Nurse-midwifery: The beneficial alternative. Public Health Reports 112(Sept/Oct): 386-394.
10.
Weisman CS, Curbow B, Khoury AL, 1995. The National Survey of Women’s Health Centers: Current models of womencentered care. Women’s Health Issues 5(3): 103-117.
11.
Short P, 1996. Medicaid’s Role in Insuring Low-Income Women, [ONLINE]. Available: http://www.cmwf.org/short.htm.
12.
Rosenbaum S, Darnell J, 1997. An Analysis of the Medicaid and Health-Related Provisions of the Personal Responsibility
and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193). Washington, DC: Kaiser Commission on the Future of
Medicaid.
13.
Davis K, 1997. Uninsured in an era of managed care. Health Services Research 31: 641-649.
14.
Singh S, Darroch Forrest J, Torres A, 1989. Prenatal Care in the United States. New York: The Alan Guttmacher
Institute.
15.
Henshaw SK, Van Vort J, 1994. Abortion services in the United States, 1991 and 1992. Family Planning Perspectives
26: 100-106, 112.
16.
Bernstein AB, 1996. Women’s health in HMOs: What do we know and what do we need to find out? Women’s Health
Issues 6: 51-59.
17.
Salganicoff A, 1997. Medicaid and managed care: Implications for low-income women. Journal of the American
Medical Women’s Association 52: 78-80.
Public Health Roles Promoting the Health and Well-Being of Women
1.
Institute of Medicine, 1988. The Future of Public Health. Washington, DC: National Academy Press.
2.
Dievler A, Grason H, Guyer B, 1997. MCH functions framework: A guide to the role of government in maternal and
child health in the 21st century. Maternal and Child Health Journal 1(1): 5-13.
3.
Grason H, Guyer B, 1995. Public MCH Program Functions Framework: Essential Public Health Services to Promote
Maternal and Child Health in America. Baltimore, MD: The Women’s and Children’s Health Policy Center, The Johns
Hopkins University.
4.
Weisman C, 1998. Women’s Health Care: Activist Traditions and Institutional Change. Baltimore, MD: The Johns
Hopkins University Press.
75
Charting a Course for the Future of Women’s and Perinatal Health
Women’s Reproductive Health and Their Overall Well-Being
1.
Division of STD Prevention, 1997. Sexually Transmitted Disease Surveillance, 1996. Atlanta, GA: Centers for Disease
Control and Prevention, Public Health Service, U.S. Department of Health and Human Services.
2.
Fleming D, McQuillan G, Johnson, RE, Nahmias A, Aral S, Lee F, St. Louis M, 1997. Herpes simplex virus type 2 in the
United States, 1976 to 1994. New England Journal of Medicine 337(16): 1105-1111.
3.
Centers for Disease Control and Prevention, 1997. HIV/AIDS Surveillance Report. CDC Surveillance Report 9(1).
4.
Viscidi R, Kotloff K, Clayman B, Russ K, Shapiro S, Shah K, 1997. Prevalance of antibodies to human papillomavirus
(HPV) type 16 virus-like particles in relation to cervical HPV infection among college women. Clinical Diagnosis Lab
Immunology 4(2): 122-126.
5.
Hiller S, Nugent R, Eschenbach D, Krohn M, Gibbs R, Martin D, Cotch M, Edelman R, Pastorek J, Rao A, et al., 1995.
Association between bacterial vaginosis and preterm delivery of a low-birth-weight infant. New England Journal of
Medicine 333(26): 1737-1742.
6.
National Center for Health Statistics, 1996. Healthy People 2000 Review 1995-96. Hyattsville, MD: Public Health
Service.
7.
Eng TR, Butler WT, 1997. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National
Academy Press.
8.
Center for Sexually Transmitted Diseases, 1997. STD Prevention and Research: A Wise Investment. Washington, DC:
Centers for Disease Control and Prevention.
9.
Ries L, Kosary C, Hankey B, Miller B, Edwards B, 1998. SEER Cancer Statistics Review, 1973-1995. Bethesda, MD:
National Cancer Institute.
10.
American Cancer Society, 1997. Cancer Facts and Figures, 1997. Washington, DC: American Cancer Society.
11.
Walker R, Lees E, Webb M, Dearing S, 1996. Breast carcinomas occuring in young women (<35 years) are different.
British Journal of Cancer 741: 1796-1800.
12.
Centers for Disease Control and Prevention, 1997. The National Breast and Cervical Cancer Early Detection Program.
Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.
13.
Chu K, Tarone R, Kessler L, et al., 1996. Recent trends in U.S. breast cancer incidence, survival, and mortality rates.
Journal of the National Cancer Institute 88: 1571-1579.
14.
1995. Rates of Cesarean Delivery–United States, 1993. MMWR 44(15): 303-307.
15.
National Center for Health Statistics, 1997. Rates of Cesarean birth and vaginal birth after previous cesarean, 19911995. Monthly Vital Statistics Report 45: 1-11.
16.
Petitti D, 1985. Maternal mortality and morbidity in cesarean section. Clinics in Obstetrics and Gynecology 28: 763.
17.
Sachs B, Kobelin C, Castro M, Frigoletto F, 1999. Risk of lowering the cesarean-delivery rate. New England Journal of
Medicine 340(1): 54-57.
18.
Beutner K, Tyring S, 1997. Human papillomavirus and human disease. American Journal of Medicine 102: 9-15.
19.
Verdon M, 1997. Issues in the management of the human papillomavirus genital disease. American Family Physician
55: 1813-1816.
20.
Hulka B, 1997. Epidemiologic analysis of breast and gynecologic cancers. Progressive Clinical Biological Research 396:
17-29.
21.
Munoz N, Bosch F, 1996. The causal link between HPV and cervical cancer and its implications for prevention of cervical cancer. Bulletin of the Pan American Health Organization 30: 362-377.
22.
Turek L, Smith E, 1996. The genetic program of genital human papillomaviruses in infection and cancer. Obstetrics
and Gynecology Clinics of North America 23: 735-758.
23.
Stoler M, 1996. A brief synopsis of the role of human papillomaviruses in cervical carcinogenesis. American Journal
of Obstetrics and Gynecology 175: 1091-1098.
76
Charting a Course for the Future of Women’s and Perinatal Health
24.
Phillips AN, Smith GD, 1994. Cigarette smoking as a potential cause of cervical cancer: Has confounding been controlled? International Journal of Epidemiology 23: 42-49.
25.
Simons A, van Herckenrode C, Rodriguez J, Maitland N, Anderson M, Phillips D, 1996. Demonstration of smokingrelated damage in cervical epithelium and correlation with human papillomavirus type 16, using exfoliated cervical
cells. British Journal of Cancer 71: 246-249.
26.
Engeland A, Andersen A, Haldorsen T, Tretli S, 1996. Smoking habits and risk of cancers other than lung cancer: 28
years’ follow-up of 26,000 Norwegian men and women. Cancer Causes and Control 7: 497- 506.
27.
Velentgas P, Daling J, 1994. Risk factors for breast cancer in younger women. Journal of the National Cancer Institute
16: 15-24.
28.
Kelsey J, 1993. Breast cancer epidemiology: Summary and future directions. Epidemiologic Reviews 15: 256-263.
29.
Willet WC, 1991. Diet and human cancer. In Brugge J, et al., eds. Origins of Human Cancer: A Comprehensive Review.
New York: Cold Spring Harbor Laboratory Press.
30.
Huang Z, Hankinson SE, Colditz GA, et al., 1997. Dual effects of weight and weight gain on breast cancer risk. JAMA
278: 1407-1411.
31.
Bernstein L, et al., 1994. Physical exercise and reduced risk of breast cancer in young women. Journal of the National
Cancer Institute 86: 1403-1408.
32.
Gammon M, John E, Britton J, 1998. Recreational and occupational physical activities and risk of breast cancer.
Journal of the National Cancer Institute 90(2): 100-117.
33.
Thune I, Brenn T, Lund E, Gaard M, 1997. Physical activity and the risk of breast cancer. New England Journal of
Medicine 336: 1269-1275.
34.
Peipert JG, Bracken MD, 1993. Maternal age: An independent risk factor for cesarean delivery. Obstetrics and
Gynecology 81: 200-205.
35.
Thomson M, Hanley J, 1988. Factors predisposing to difficult labor in primiparas. American Journal of Obstetrics and
Gynecology 158: 1074-1078.
36.
Witter F, Caulfield L, Stoltzfus R, 1995. Influence of maternal anthropometric status and birth weight on the risk of
cesarean delivery. Obstetrics and Gynecology 85: 947-951.
37.
Rosenblatt RA, Dobie SA, Hart LG, Schneeweiss R, Gould D, Raine TR, Benedetti TJ, Pirani MJ, Perrin EB, 1997.
Interspecialty differences in the obstetric care of low-risk women. American Journal of Public Health 87(3): 344-351.
38.
Butler J, Abrams B, Parker J, Roberts J, Laros R, 1993. Supportive nurse-midwife care is associated with a reduced incidence of cesarean section. American Journal of Obstetrics and Gynecology 168: 1407-1413.
39.
Ruderman J, Carroll J, Reid A, Murray M, 1993. Are physicians changing the way they practice obstetrics? The
Canadian Medical Association Journal 148: 409-415.
40.
Berkowitz G, Fiarman G, Mojica M, Bauman J, Hynes de Regt R, 1989. Effect of physician characteristics on the cesarean birth rate. American Journal of Obstetrics and Gynecology 161: 146-149.
41.
Gleicher N, 1984. Cesarean section rates in the United States: The short-term failure of the National Consensus
Development Conference in 1980. JAMA 252: 3273-3276.
42.
Eskew P, Saywell J, Zollinger T, Erner B, Oser T, 1994. Trends in the frequency of cesarean delivery: A 21-year experience, 1970-1990. Journal of Reproductive Medicine 39: 809-817.
43.
Bandura A, 1977. Social Learning Theory. Englewood, NJ: Prentice-Hall.
44.
Rogers EE, 1983. Diffusion of Innovations. New York: Free Press.
45.
Thompson J, Hochheimer JN, Schifrin E, Kim N, 1998. Nationwide Comparison of Women’s Health Indicators Among
Managed Care Plans. The future of managed care and women’s health: New directions for the 21st century.
Washington, DC: U.S. Public Health Service, Office on Women’s Health.
77
Charting a Course for the Future of Women’s and Perinatal Health
Pregnancy Planning and Unintended Pregnancy
1.
Institute of Medicine, 1995. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families.
Washington, DC: National Academy Press.
2.
Zabin L, Hayward S, 1993. Adolescent Sexual Behavior and Childbearing. Newbury Park, CA: Sage Publications.
3.
Piccinino L, 1995. Unintended pregnancy and childbearing. In Wilcox L, Marks J, eds. From Data to Action: CDC’s
Public Health Surveillance for Women, Infants, and Children. Atlanta, GA: U.S. Department of Health and Human
Services, Public Health Service.
4.
Forrest J, Singh S, 1990. The sexual and reproductive behavior of American women 1982-1988. Family Planning
Perspectives 22: 206-214.
5.
1997. Contraception Counts: State-by-State Information. Issues in Brief. New York: The Alan Guttmacher Institute.
6.
Ventura S, Clarke S, Matthews T, 1996. Recent declines in teenage birth rates in the United States: Variations by state,
1990-1994. Monthly Vital Statistics Report 45(5): supplement.
7.
Ventura S, Mathews T, Curtin S, 1998. Declines in teenage birth rates, 1991-97: National and State patterns. National
Vital Statistics Reports 47(12): 1-18.
8.
1996. The World’s Youth 1996. Chart. Washington, DC: Population Reference Bureau.
9.
Ventura SJ, Peters KD, Martin JA, Maurer JD, 1997. Births and deaths: United States, 1996. Monthly Vital Statistics
Report 46(1): 1-41.
10.
Joyce T, Grossman M, 1990. Pregnancy wantedness and the initiation of prenatal care. Demography 27: 1-17.
11.
Lia-Hoagberg B, et al., 1990. Barriers and motivators to prenatal care among low-income women. Social Science and
Medicine 30: 487-495.
12.
Sable M, et al., 1990. Differentiating the barriers to adequate prenatal care in Missouri, 1987-88. Public Health Reports
105: 549-555.
13.
Weller R, Eberstein I, Bailey M, 1987. Pregnancy wantedness and maternal behavior during pregnancy. Demography
24: 407-412.
14.
Bustan MN, Coker AL, 1994. Maternal attitude toward pregnancy and the risk of neonatal death. American Journal of
Public Health 84: 411-414.
15.
Sable M, Spencer J, Stockbauer J, Schramm W, Howell W, Herman A, 1997. Pregnancy wantedness and adverse pregnancy outcomes: Differences by race and Medicaid status. Family Planning Perspectives 29(2): 76-81.
16.
Bitto A, Gray RH, Simpson JL, Queenan JT, Kambic RT, Perez A, Mena P, Barbato M, Li C, Jennings V, 1997. Adverse
outcomes of planned and unplanned pregnancies among users of natural family planning: A prospective study.
American Journal of Public Health 87(3): 338-343.
17.
Lee P, Stewart F, 1995. Editorial: Failing to prevent unintended pregnancy is costly. American Journal of Public Health
85: 479-480.
18.
1994. Sex and America’s Teenagers. New York: The Alan Guttmacher Institute.
19.
U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, 1997.
A National Strategy to Prevent Teen Pregnancy. Washington, DC: U.S. Department of Health and Human Services.
20.
National Center for Health Statistics, Public Health Service, Department of Health and Human Services, 1993. Advance
report of final natality statistics, 1991. Monthly Vital Statistics Report 42(3 Suppl.).
21.
Kalmuss D, Namerow P, 1994. Subsequent childbearing among teenage mothers: The determinants of a closely spaced
second birth. Family Planning Perspectives 26(4): 149-53.
22.
Brody DJ, Bracken MD, 1987. Short interpregnancy interval: A risk factor for low birthweight. American Journal of
Perinatology 4: 50-54.
78
Charting a Course for the Future of Women’s and Perinatal Health
23.
Huttly S, Victora C, Barros F, Vaughan J, 1992. Birth spacing and child health in urban Brazilian children. Pediatrics
89: 1049-54.
24.
Lieberman E, Lang J, Ryan K, Monson R, Schoenbaum S, 1989. The association of inter-pregnancy interval with small
for gestational age births. Obstetrics and Gynecology 74: 1-5.
25.
Miller J, 1991. Birth intervals and perinatal health: An investigation of three hypotheses. Family Planning Perspectives
23: 62-70.
26.
Harrison PF, Rosenfeld A, 1996. Contraceptive Research and Development: Looking to the Future. Washington, DC:
National Academy Press.
27.
Mosher WD, Bachrach CA, 1996. Understanding U.S. fertility: Continuity and change in the National Survey of Family
Growth, 1988-1995. Family Planning Perspectives 28: 4-12.
28.
Henshaw SK, Kost K, 1996. Abortion patients in 1994-1995: Characteristics and contraceptive use. Family Planning
Perspectives 28: 140-147.
29.
Trussel J, Stewart F, Guest F, Hatcher R, 1992. Emergency contraceptive pills: A simple proposal to reduce unintended pregnancies. Family Planning Perspectives 28: 228-231.
30.
1998. Emergency contraception arrives. Family Planning Perspectives 30(6): 254.
31.
Samuels S, Smith M, 1994. The Pill: From Prescription to Over the Counter. Menlo Park, CA: Kaiser Family Foundation.
32.
1996. Uneven & Unequal: Insurance Coverage and Reproductive Health Services. New York, NY: The Alan Guttmacher
Institute.
33.
Forrest J, 1994. Epidemiology of unintended pregnancy and contraceptive use. American Journal of Obstetrics and
Gynecology 170: 1485-1488.
34.
Sollom T, Gold RB, Saul R, 1996. Public funding for contraceptive sterilization and abortion services, 1994. Family
Planning Perspectives 28: 166-173.
35.
Henshaw SK, 1995. Factors hindering access to abortion services. Family Planning Perspectives 27: 54-59.
36.
Kaiser Family Foundation, 1997. Women’s Experiences: Talking with Health Professionals About STDs. Menlo Park, CA:
Kaiser Family Foundation.
37.
Beatty ME, Lewis J, 1994. Adolescent contraceptive counseling and gynecology: A deficiency in pediatric office-based
care. Connecticut Medicine 58(2): 71-78.
38.
Patton D, Kolassa K, West S, Irons T, 1995. Sexual abstinence counseling of adolescents by physicians. Adolescence
30(120): 963-969.
39.
Clancy CM, Massion CT, 1992. American women’s health care: A patchwork quilt with gaps. JAMA 268: 1918- 1920.
40.
Gonen JS, 1997. Women’s Primary Care in Managed Care: Clinical and Provider Issues. Insights January 1997(No. 1).
41.
Roter DL, Hall JA, in press. Gender differences in patient-physician communication. In S J Gallant, et. al., eds.
Psychosocial and Behavioral Factors in Women’s Health. Washington, DC: American Psychological Association.
42.
Gonen JS, 1997. Managed Care and Unintended Pregnancy: Testing the Limits of Prevention. Insights July 1997(No. 3).
43.
Sonenstein F, Ku L, Schulte M, 1995. Reproductive health care delivery: Patterns in a changing market. The Western
Journal of Medicine 163(3 supplement): 7-14.
44.
Stein Z, 1996. Editorial: Family planning, sexually transmitted diseases, and the prevention of AIDS–divided we fail?
American Journal of Public Health 86(6): 783-4.
45.
Schulte M, Sonnenstein F, 1995. Men at Family Planning Clinics: The New Patients? Family Planning Perspectives 28:
261-266.
46.
1996. The New Welfare Reform Law: Provisions Affecting Reproductive Health. New York: The Alan Guttmacher
Institute.
79
Charting a Course for the Future of Women’s and Perinatal Health
Issues in Pregnancy Care
1.
Ventura SJ, Taffel SM, Mosher WD, Wilson JB, Henshaw S, 1995. Trends in pregnancies and pregnancy rates: Estimates
for the United States, 1980-92. Monthly Vital Statistics Report 43(11S): 1-24.
2.
Abma JC, Chandra A, Mosher WD, 1997. Fertility, family planning, and women’s health: New data from the 1995
National Survey of Family Growth. Vital Health Statistics 23(19): 1-28.
3.
Ventura SJ, Martin JA, Curtin SC, Mathews TJ, 1998. Report of final natality statistics, 1996. Monthly Vital Statistics
Report 46(11S): 1-99.
4.
Buescher PA, Taylor KP, Davis MH, Bowling, JM, 1993. The quality of the new birth certificate data: A validation study
in North Carolina. American Journal of Public Health 83(8): 1163-5.
5.
Bennett T, Kotelchuck M, Cox CE, Tucker MJ, Nadeau DA, 1998. Pregnancy-associated hospitalizations in the United
States in 1991 and 1992: A comprehensive view of maternal morbidity. American Journal of Obstetrics and Gynecology
178: 346-354.
6.
Franks AL, Kendrick JS, Olson DR, Atrash HK, Saftlas AF, Moien M, 1992. Hospitalization for pregnancy complications,
United States, 1986 and 1987. American Journal of Obstetrics and Gynecology 166(5): 1339-1344.
7.
Scott CL, Chavez GF, Atrash HK, Taylor DJ, Shah RS, Rowley D, 1997. Hospitalizations for severe complications of
pregnancy, 1987-1992. Obstetrics and Gynecology 90(2): 225-229.
8.
Adams M, Harlass F, Sarno A, Read J, Rawlings J, 1994. Antenatal hospitalization among enlisted servicewomen, 19871990. Obstetrics and Gynecology 84(1): 35-9.
9.
Haas J, Berman S, Goldberg A, Lee L, Cook E, 1996. Prenatal hospitalization and compliance with guidelines for prenatal care. American Journal of Public Health 86(6): 815-9.
10.
Goldenberg RL, Cliver SP, Bronstein J, Cutter GR, Andrews WW, Mennemeyer ST, 1994. Bed rest in pregnancy.
Obstetrics and Gynecology 84(1): 131-136.
11.
Crowther C, Verkuyl D, Ashworth M, Bannerman C, Ashurst H, 1991. The effects of hospitalization for bed rest on
duration of gestation, fetal growth and neonatal morbidity in triplet pregnancy. Acta Genet Med Gemellol (Roma)
40(1): 63-8.
12.
Lockwood CJ, Senyei AE, Dische MR, Casal D, Shah KD, Thung SN, Jones L, Deligdisch L, Garite TJ, 1991. Fetal
fibronectin in cervical and vaginal secretions as a predictor of preterm delivery. New England Journal of Medicine
325: 669-674.
13.
Scott J, 1986. Spontaneous abortion. In Danford D, Scott J, eds. Obstetrics and Gynecology. Philadelphia, PA: JB
Lippincott, 378-386.
14.
Maloni J, 1993. Bed rest during pregnancy: Implications for nursing. Journal of Obstetric, Gynecologic, & Neonatal
Nursing 22(5): 422-6.
15.
Allen M, Chavkin W, Marinoff J, 1991. Ascertainment of maternal deaths in New York City. American Journal of Public
Health 81(3): 380-2.
16.
1998. Maternal Mortality—United States, 1982-1996. MMWR 47(34): 705-7.
17.
Berg CJ, Atrash HK, Koonin LM, Tucker M, 1996. Pregnancy-related mortality in the United States, 1987-1990.
Obstetrics and Gynecology 88(2): 161-167.
18.
Koonin LM, MacKay AP, Berg CJ, Atrash HK, Smith JC, 1997. Pregnancy-related mortality surveillance—United States,
1987-1990. MMWR 46(SS-4): 17-36.
19.
Behrman REE, 1995. Low birth weight. The Future of Children 5(1): 4-231.
20.
Morrison J, 1990. Preterm birth: A puzzle worth solving. Obstetrics and Gynecology 76(1 Supplement): 5S-12S.
21.
McLean M, Walters W, Smith R, 1993. Prediction and early diagnosis of preterm labor: a critical review. Obstetrical
and Gynecological Survey 48(4): 209-225.
22.
Shiono P, Behrman R, 1995. Low birth weight: analysis and recommendations. The Future of Children 5(1): 4-18.
80
Charting a Course for the Future of Women’s and Perinatal Health
23.
U.S. Department of Health and Human Services, 1989. Caring for our future: The content of prenatal care. A report of the
Public Health Service Expert Panel on the Content of Prenatal Care. Washington, DC: U.S. Department of Health and
Human Services.
24.
Jack B, Culpepper L, 1990. Preconception care. In Merkatz IR, Thompson JE, eds. New Perspectives on Prenatal Care.
New York: Elsevier.
25.
Korenbrot CC, 1984. Risk reduction in pregnancies of low income women. Mobius 4(3): 35-43.
26.
Peoples MD, Grimson RC, Daughtry GL, 1984. Evaluation of the effects of the North Carolina improved pregnancy
outcome project: Implications for state-level decision making. American Journal of Public Health 74: 549-554.
27.
Buescher PA, Meis PJ, Ernest JM, Moore ML, Michielutte R, Sharp P, 1988. A comparison of women in and out of a
Prematurity Prevention Project in a North Carolina perinatal care region. American Journal of Public Health 78: 264-267.
28.
Handler A, Rosenberg D, 1992. Improving pregnancy outcomes: Public versus private care for urban, low-income
women. Birth 19(3): 123-130.
29.
Buescher PA, Ward NI, 1992. A comparison of low birth weight among Medicaid patients of public health departments
and other providers of prenatal care in North Carolina and Kentucky. Public Health Reports 107(1): 54-59.
30.
Strong Jr T, Brown Jr W, Brown W, Curry C, 1993. Experience with early postcesarean hospital dismissal. American
Journal of Obstetrics and Gynecology 169(1): 116-9.
31.
Theobald G, 1959. Home on the second day: The Bradford experiment: The combined maternity scheme. British
Medical Journal 2: 1364-1367.
32.
Braverman P, Egerter S, Pearl M, Marchi K, Miller C, 1995. Problems associated with early discharge of infants. Early
discharge of newborns and mothers: A critical review of the literature. Pediatrics 96: 716-726.
33.
Levy H, 1995. Is early discharge a problem for newborn screening? In Pass KA, Levy HL, eds. Early Hospital Discharge:
Impact on Newborn Screening. Atlanta, GA: The Council of Regional Networks for Genetic Services, Emory University
School of Medicine, 23-30.
34.
Naylor E, 1995. Impact of early hospital discharge on newborn screening for sickle cell disease, homocystinuria and
maple syrup urine disease. In Pass KA, Levy HL, eds. Early Hospital Discharge: Impact on Newborn Screening. Atlanta,
GA: The Council of Regional Networks for Genetic Services, Emory University School of Medicine, 126-132.
35.
Panny S, 1995. Problems associated with early discharge experienced by the Maryland Newborn Screening Program:
Effectiveness and limitations of voluntary repeat screening. In Pass KA, Levy HL, eds. Early Hospital Discharge: Impact
on Newborn Screening. Atlanta, GA: The Council of Regional Networks for Genetic Services, Emory University School
of Medicine, 213-232.
36.
Beck C, 1991. Early postpartum discharge programs in the United States: A literature review and critique. Women’s
Health 17: 125-138.
37.
Britton J, Britton H, Beebe S, 1994. Early discharge of the term newborn: a continued dilemma. Pediatrics 94(3): 291-5.
38.
Norr K, 1987. Outcomes of postpartum early discharge, 1960-1986. A comparative review. Birth 14(3): 135-41.
39.
American Academy of Pediatrics, 1995. Policy Statement: Post-Delivery Care for Mothers and Newborns Act, [ONLINE].
Available: http://www.aap.org/policy/968.html.
40.
American College of Obstetricians and Gynecologists (ACOG), 1996. Maternal Serum Screening. ACOG Educational
Bulletin 228: 1-9.
41.
Goldenberg R, Rouse D, 1998. Prevention of premature birth. New England Journal of Medicine 339(5): 313-320.
42.
Guyer B, MacDorman MF, Martin JA, Peters KD, Strobino DM, 1998. Annual summary of vital statistics–1997. Pediatrics
102(6): 1333-1349.
43.
American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG), 1997.
Guidelines for Perinatal Care. Washington, DC: American Academy of Pediatrics and American College of
Obstetricians and Gynecologists.
44.
Baldwin LM, Raine T, Jenkins LD, Hart GL, Rosenblatt R, 1994. Do providers adhere to ACOG standards? The case of
prenatal care. Obstetrics and Gynecology 84(4): 549-556.
81
Charting a Course for the Future of Women’s and Perinatal Health
45.
Bronstein JM, Cliver SP, Goldenberg RL, 1998. Practice variation in the use of interventions in high-risk obstetrics.
Health Services Research 32(6): 825-839.
46.
Haas J, Udvarhelyi I, Morris C, Epstein A, 1993. The effect of providing health coverage to poor uninsured pregnant
women in Massachusetts. JAMA 269(1): 87-91.
47.
Horton J, 1995. The Women’s Health Data Book: A Profile of Women’s Health in the United States. Washington DC:
Jacobs Institute of Women’s Health.
48.
U.S. Department of Labor, 1996. Questions & Answers: Recent Changes in Health Care Law. Washington, DC: U.S.
Department of Labor, Pension and Welfare Benefits Administration.
49.
Minkoff H, Bauer T, Joyce T, 1997. Welfare reform and the obstetrical care of immigrants and newborns. New England
Journal of Medicine 337: 705-707.
50.
Health Care Financing Administration, Data and Systems Group, 1997. National Summary of Medicaid Managed Care
Programs and Enrollment, [ONLINE]. Available: http://www.hcfa.gov/medicaid/trends97.htm.
51.
Delbanco S, Smith MD, 1995. Reproductive health and managed care: An overview. The Western Journal of Medicine
163(3 supplement): 1-6.
52.
Goldfarb N, Hillman A, Eisenberg J, Kelley M, Cohen A, Dellheim M, 1991. Impact of a Mandatory Medicaid Case
Management Program on Prenatal Care and Birth Outcomes. Medical Care 29(1): 64-71.
53.
McCormick M, Shapiro S, Starfield B, 1985. The regionalization of perinatal services: Summary of the evaluation of a national demonstration program. JAMA 253(6): 799-804.
54.
Phibbs CS, Bronstein JM, Buxton E, Phibbs RH, 1996. The effects of patient volume and level of care at the hospital
of birth on neonatal mortality. JAMA 276(13): 1054-1059.
55.
Mayfield JA, Rosenblatt RA, Baldwin LM, Chu J, Logerfo JP, 1990. The relation of obstetrical volume and nursery level
to perinatal mortality. American Journal of Public Health 80(7): 819-823.
Women’s Experience of Chronic Diseases
1.
Collins JG, 1997. Prevalence of selected chronic conditions: United States, 1990-1992. Vital Health Statistics 10(194): 1-89.
2.
Benson V, Marano MA, 1998. Current estimates from the National Health Interview Survey, 1995. Vital Health Statistics
10(199): 80, 82.
3.
Kelley MA, Perloff JD, Morris NM, Liu W, 1992. Primary care arrangements and access to care among African-American
women in three Chicago communities. Women and Health 18: 91-106.
4.
West KM, Kaflebleisch JM, 1971. Influence of nutritional factors on prevalence of diabetes. Diabetes 20: 99.
5.
Coulston AM, 1996. Diabetes. In Krummel DA, Kris-Etherton PM, eds. Nutrition in Women’s Health. Gaithersburg, MD:
Aspen Publishers.
6.
Brunzell JB, Lerner RL, Porte O, Eirmann EL, 1974. Effect of fat-free high carbohydrate diet on diabetic subjects with
fasting hypoglycemia. Diabetes 23: 128.
7.
Weiss S, Speizer F, 1993. Epidemiology and natural history. In Weiss E, Stein M, eds. Bronchial Asthma: Mechanisms
and Therapeutics. Boston, MA: Little Brown and Company, 15-25.
8.
Martenez FD, Clince M, Burrows B, 1992. Increased incidence of asthma in children of smoking mothers. Pediatrics
89: 21-26.
9.
Reece EA, 1996. Diabetes in Pregnancy. Obstetrics and Gynecology Clinics of North America 23(1): 1-171.
10.
Folsom AR, Caspersen CJ, Taylor HL, Jacobs DR, Luepker RV, Gomez-Marin L, Gillum RF, Blackburn H, 1985. Leisure
time physical activity and its relationship to coronary risk factors in a population-based sample: The Minnesota Heart
Survey. American Journal of Epidemiology 121: 570-579.
82
Charting a Course for the Future of Women’s and Perinatal Health
11.
Blair SN, Goodyear NN, Gibbons LW, Cooper KH, 1984. Physical fitness and incidence of hypertension in healthy normotensive men and women. JAMA 242: 487-490.
12.
Horton E, 1973. The role of exercise in prevention and treatment of obesity. In Bray G, ed. Obesity in Perspective.
Bethesda, MD: U.S. Department of Health, Education, and Welfare, 62-66.
13.
Robinson DM, Egglestone DM, Hill PM, Rea HH, Richards GN, Robinson SM, 1992. Effects of a physical conditioning
programme on asthmatic patients. New Zealand Medical Journal 105: 253-256.
14.
Spelsberg A, Manson JE, 1995. Physical activity in the treatment and prevention of diabetes. Comprehensive Therapy
21: 559-562.
15.
Seals DR, Silverman HG, Reiling MJ, Davy KP, 1997. Effect of regular aerobic exercise on elevated blood pressure in
postmenopausal women. American Journal of Cardiology 80(1): 49-55.
16.
Cohen S, Williamson GM, 1991. Stress and infectious disease in humans. Psychological Bulletin 109(1): 5-24.
17.
Adams PF, Marano MA, 1995. Current estimates from the National Health Interview Survey, 1994. Vital Health Statistics
10(193): 1-520.
18.
Cefalo R, Moos M, 1995. Preconceptional Health Care: A Practical Guide, 2nd Edition. St. Louis, MO: Mosby.
19.
Haas JS, Berman S, Goldberg AB, Lee LWK, Cook EF, 1996. Prenatal hospitalization and compliance with guidelines
for prenatal care. American Journal of Public Health 86: 815-819.
20.
Weisman C, 1996. Women’s use of health care. In Falik MM, Collins KS, eds. Women’s Health: The Commonwealth
Fund Survey. Baltimore, MD: Johns Hopkins University Press.
Depression in Women
1.
Gotlib IH, Whiffen VE, Mount JH, Milne K, Cordy NI, 1989. Prevalence rates and demographic characteristics associated with depression in pregnancy and the postpartum. Journal of Consulting and Clinical Psychology 57(2): 269-274.
2.
Blazer DG, Kessler RC, McGonagle KA, Swartz MS, 1994. The prevalence and distribution of major depression in a
national community sample: The National Comorbidity Survey. American Journal of Psychiatry 151: 979-986.
3.
Blumenthal SJ, 1996. Women’s mental health: The new national focus. Annals of the New York Academy of Sciences
789: 1-16.
4.
Cutrona CE, Troutman BR, 1986. Social support, infant temperament, and parenting self-efficacy: A mediational model
of postpartum depression. Child Development 57: 1507-1518.
5.
Weissman M, Bruce M, Leaf P, Florio L, 1991. Affective disorders. In Robins L, Regier D, eds. Psychiatric Disorders in
America: The Epidemiologic Catchment Area Study. New York: The Free Press, 33-52.
6.
Klerman G, Weissman M, 1989. Increasing rates of depression. JAMA 261: 2229-2235.
7.
McGrath E, Keita G, Strickland B, Russo N, 1990. Women and Depression: Risk Factors and Treatment Issues. Washington,
DC: American Psychological Association.
8.
Floyd B, 1997. Problems in accurate medical diagnosis of depression in female patients. Social Science and Medicine
44: 403-412.
9.
Denmark F, Novick K, Pinto A, 1996. Women, work, and family: Mental health issues. Annals of the New York Academy
of Sciences 789: 101-117.
10.
Hurst S, Genest M, 1995. Cognitive-behavioural therapy with a feminist orientation: A perspective for therapy with
depressed women. Canadian Psychology 36: 236-257.
11.
Meagher D, Murray D, 1997. Depression. The Lancet 349: s117-s120.
12.
Roxburgh S, 1997. The effect of children on the mental health of women in the paid labor force. Journal of Family
Issues 18: 270-289.
83
Charting a Course for the Future of Women’s and Perinatal Health
13.
Nolen-Hoeksema S, 1987. Sex differences in unipolar depression: Evidence and theory. Psychological Bulletin 101:
259-282.
14.
Nolen-Hoeksema S, Girgus J, 1994. The emergence of gender differences in depression during adolescence.
Psychological Bulletin 115: 424-443.
15.
Stowe Z, Nemeroff C, 1995. Women at risk for postpartum-onset major depression. American Journal of Obstetrics
and Gynecology 173: 639-645.
16.
Howell E, 1981. Psychological reactions of postpartum women. In Howell E, Bayes M, eds. Women and Mental Health.
New York: Basic Books, Inc., 340-346.
17.
Kitamura T, Shima S, Sugawara M, Toda M, 1993. Psychological and social correlates of the onset of affective disorders among pregnant women. Psychological Medicine 23(4): 967-75.
18.
American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders IV. Washington, DC:
American Psychiatric Association.
19.
Klerman G, Weissman M, 1992. The course, morbidity, and costs of depression. Archives of General Psychiatry 49:
831-834.
20.
Judd L, 1995. Mood disorders in the general population represent an important and worldwide public health problem. International Clinical Psychopharmacology 10(suppl 4): 5-10.
21.
American Psychiatric Association Work Group on Major Depressive Disorder, 1993. Practice guideline for major
depressive disorder in adults. American Journal of Psychiatry 150(suppl 4): 1-26.
22.
Rice D, Miller L, 1995. The economic burden of affective disorders. British Journal of Psychiatry 166(suppl 27): 34-42.
23.
Rupp A, 1995. The economic consequences of not treating depression. British Journal of Psychiatry 166(suppl 27):
29-33.
24.
Wells K, Sturm R, Sherbourne C, Meredith L, 1996. Caring for Depression. Cambridge, MA: Harvard University Press.
25.
Pajer K, 1995. New strategies in the treatment of depression in women. Journal of Clinical Psychiatry 56(2 suppl): 3037.
26.
Chisholm JF, 1996. Mental health issues in African-American women. Annals of the New York Academy of Sciences 789:
161-179.
27.
Gil R, 1996. Hispanic women and mental health. Annals of the New York Academy of Sciences 789: 147-159.
28.
Gonen JS, 1997. Managed care and women’s mental health: A focus on depression. Insights December 1997(No.5).
29.
Wells K, 1995. Cost containment and mental health outcomes: Experience from U.S. studies. British Journal of
Psychiatry 166(suppl 27): 43-51.
30.
Glied S, Koffman S, 1995. Women and Mental Health: Issues for Health Care Reform. New York: Columbia University.
31.
Glied S, 1997. The treatment of women with mental disorders under HMO and fee-for-service insurance. Women and
Health 26: 1-15.
32.
Weissman M, Olfson M, 1995. Depression in women: Implications for health care research. Science 269: 799-801.
Abuse Against Women by Their Intimate Partners
1.
Crowell NA, Burgess A, 1996. Understanding Violence Against Women. Washington, DC: National Academy Press.
2.
Bureau of Justice Statistics, 1994. Selected Findings: Violence Between Intimates. Washington, DC: U.S. Department of Justice.
3.
Kellermann A, Rivara F, Rushforth N, Banton J, Reay D, Francisco J, Locci A, Prodzinski J, Hackman B, Somes G, 1993.
Gun ownership as a risk factor for homicide in the home. New England Journal of Medicine 329: 1084-1091.
84
Charting a Course for the Future of Women’s and Perinatal Health
4.
Gazmararian JA, Adams MM, Salzman LE, Johnson CH, Bruce FC, Marks JS, Zahniser SC, 1995. The relationship between
pregnancy intendedness and physical violence in mothers of newborns. Obstetrics and Gynecology 85: 1031-1038.
5.
Falik M, Collins K, 1996. Women’s Health: The Commonwealth Fund Survey. Baltimore, MD: The Johns Hopkins
University Press.
6.
Parker B, McFarlane J, Soeken K, 1994. Abuse during pregnancy: Effects on maternal complications and birth weight
in adult and teenage women. Obstetrics and Gynecology 84(3): 323-328.
7.
Berenson A, Wiemann C, Wilkinson G, Jones W, Anderson G, 1994. Perinatal morbidity associated with violence experienced by pregnant women. American Journal of Obstetrics and Gynecology 170(6): 1760-1766.
8.
Webster J, Chandler J, Battistutta D, 1996. Pregnancy outcomes and health care use: Effects of abuse. American
Journal of Obstetrics and Gynecology 174(2): 760-767.
9.
Miller TR, Cohen MA, Wiersema B, 1995. Crime in the United States: Victim Costs and Consequences. Final Report to
the National Institute of Justice. Washington, DC: National Institute of Justice.
10.
Hyman A, Schillinger D, Lo B, 1995. Laws mandating reporting of domestic violence. Do they promote patient wellbeing? JAMA 273(22): 1781-1787.
11.
Gondolf E, 1997. Batterer programs: What we know and need to know. Journal of Interpersonal Violence 12(1): 83-98.
12.
Gerlock A, 1997. New directions in the treatment of men who batter women. Health Care Women International 18(5):
481-493.
13.
Sonkin D, 1988. The male batterer: Clinical and research issues. Violence Victims 3(1): 65-79.
14.
Omnibus Consolidated Appropriations Act of 1997, Pub. L. No. 104-208, § 658 (1996).
15.
Dohrn B, 1995. Bad mothers, good mothers, and the state: Children on the margins. The Newsletter of the Maternal
and Child Community Health Science Consortium Summer(3): 7-9.
16.
Sugg N, Inui T, 1992. Primary care physicians’ response to domestic violence. JAMA 267(23): 3157-3160.
17.
Taylor RB, 1997. Preventing Violence Against Women and Children. New York: Milbank Memorial Fund.
The Nutritional Status and Needs of Women of Reproductive Age
1.
Bidlack WR, 1996. Interrelationships of food, nutrition, diet and health: The National Association of State Universities
and Land Grant Colleges White Paper. Journal of the American College of Nutrition 15(5): 422-433.
2.
National Heart, Lung and Blood Institute, 1998. Clinical Guidelines on the Identification, Evaluation, and Treatment
of Overweight and Obesity in Adults: The Evidence Report. Washington, DC: National Institutes of Health.
3.
Heaney RP, 1996. Osteoporosis. In Krummel DA, Kris-Etherton PM, eds. Nutrition in Women’s Health. Gaithersburg,
MD: Aspen Publishers.
4.
Institute of Medicine, 1993. Iron Deficiency Anemia: Recommended Guidelines for the Prevention, Detection, and
Management among U.S. Children and Women of Childbearing Age. Washington, DC: National Academy of Sciences.
5.
Wald NJ, 1995. Folic acid and the prevention of neural tube defects: A population strategy is needed. BMJ 310: 1019-1020.
6.
Mills JL, Scott JM, Kirke PN, McPartlin JM, Conley MR, Weir DG, Molloy AM, Lee YJ, 1996. Homocysteine and neural
tube defects. Journal of Nutrition 126: 756S-760S.
7.
Boushey CJ, Beresford SAA, Omenn GS, Motulsky AG, 1995. A quantitative assessment of plasma homocysteine as a
risk factor for vascular disease. JAMA 274(13): 1049-1057.
8.
Bowen DJ, Tomoyasu N, Cauce AM, 1991. The triple threat: A discussion of gender, class, and race differences in
weight. Women and Health 17(4): 123-143.
85
Charting a Course for the Future of Women’s and Perinatal Health
9.
Caulfield LE, Witter FR, Stoltzfus RJ, 1996. Determinants of gestational weight gain outside the recommended ranges
among black and white women. Obstetrics and Gynecology 87(5): 760-766.
10.
Johnson RK, 1996. Normal nutrition in premenopausal women. In Krummel DA, Kris-Etherton PM, eds. Nutrition in
Women’s Health. Gaithersburg, MD: Aspen Publishers, 174-211.
11.
Devine CM, Olson CM, 1992. Women’s perceptions about the way social roles promote or constrain personal nutrition care. Women and Health 19(1): 79-95.
12.
Kiger G, Riley PJ, 1996. Gender differences in perceptions of household labor. The Journal of Psychology 130(4): 357-370.
13.
Grodstein F, Goldman MB, Cramer DW, 1994. Body mass index and ovulatory infertility. Epidemiology 5(2): 247- 250.
14.
Krummel DA, Kris-Etherton PM, eds., 1996. Nutrition in Women’s Health. Gaithersburg, MD: Aspen Publishers.
15.
Lindenbaum J, Rosenberg IH, Wilson PWF, Stabler SP, Allen RH, 1994. Prevalence of cobalamin deficiency in the
Framingham elderly population. American Journal of Clinical Nutrition 60: 2-11.
16.
Heaney RP, 1991. Effect of calcium on skeletal development, bone loss, and risk of fractures. American Journal of
Medicine 91(5B): 23s-28s.
17.
Institute of Medicine, 1997. Schools and Health: Our Nation’s Investment. Washington, DC: National Academy Press.
18.
Food and Drug Administration, 1996. Food labeling: Health claims and food label statements; folate and neural tube
defects. Federal Register 61(44): 8752-8807.
Women’s Physical Activity in Leisure, Occupational, and Daily Living Activities
1.
U.S. Department of Health and Human Services, 1996. Physical Activity and Health: A Report of the Surgeon General.
Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health
Promotion, U.S. Department of Health and Human Services.
2.
Bielenda CC, Knapik J, Wright DA, 1993. Physical fitness and cardiovascular disease risk factors of female senior U.S.
military officers and federal employees. Military Medicine 158(3): 177-181.
3.
Lindenstrom E, Boyson G, Nyboe J, 1993. Lifestyle factors and risk of cerebrovascular disease in women: The Copenhagen
City Heart Study. Stroke 24(10): 1468-1472.
4.
Buckworth J, Dishman RK, Cureton KJ, 1994. Autonomic response of women with parental hypertension: Effects of
physical activity and fitness. Hypertension 24(5): 576-584.
5.
He J, Whelton PK, 1997. Epidemiology and prevention of hypertension. Medical Clinics of North America 81(5): 1077-1097.
6.
Goldbourt U, 1997. Physical activity, long-term CHD mortality and longevity: A review of studies over the last 30 years.
World Review of Nutrition and Dietetics 82: 229-239.
7.
Helmrich SP, Ragland DR, Leung RW, Paffenbarger RS, 1991. Physical activity and reduced occurrence of
non-insulin-dependent diabetes mellitus. New England Journal of Medicine 325: 147-152.
8.
Manson JE, Rimm EB, Stampfer MJ, Colditz GA, Willet WC, Krolewski AS, 1991. Physical activity and incidence of noninsulin-dependent diabetes mellitus in women. Lancet 338: 774-778.
9.
Paffenbarger RS, Lee IM, Kampert JB, 1997. Physical activity in the prevention of non-insulin-dependent diabetes mellitus. World Review of Nutrition and Dietetics 82: 210-218.
10.
Bowman MA, Spangler JG, 1997. Osteoporosis in women. Primary Care 24(1): 27-36.
11.
Deuster PA, Jones BH, Moore J, 1997. Patterns and risk factors for exercise-related injuries in women: A military perspective. Military Medicine 162(10): 649-655.
12.
Marchigiano G, 1997. Osteoporosis: Primary prevention and intervention strategies for women at risk. Home Care
Provider 2(2): 76-81.
86
Charting a Course for the Future of Women’s and Perinatal Health
13.
National Institute of Diabetes and Diseases of the Kidneys, 1996. Physical Activity and Weight Control. Bethesda, MD:
National Institutes of Health.
14.
Glenny AM, O’Meara S, Melville A, Sheldon TA, Wilson C, 1997. The treatment and prevention of obesity: A systematic review of the literature. International Journal of Obesity-Related Metabolism Disorders 21(9): 715-737.
15.
Keller C, Oveland D, Hudson S, 1997. Strategies for weight control success in adults. Nurse Practitioner 22(3): 33-54.
16.
Klem ML, Wing RR, McGuire MT, Seagle HM, Hill JO, 1997. A descriptive study of individuals successful at long-term
maintenance of substantial weight loss. American Journal of Clinical Nutrition 66(2): 239-246.
17.
Bryner RW, Toffle RC, Ullrich IH, Yeater RA, 1997. The effects of exercise intensity on body composition, weight loss,
and dietary composition in women. Journal of the American College of Nutrition 16(1): 68-73.
18.
Maughan R, Aulin KP, 1997. Energy costs of physical activity. World Review of Nutrition and Dietetics 82: 18-32.
19.
Marcus BH, Albrecht AE, Niaura RS, Taylor ER, Simkin LR, Feder SI, Abrams DB, Thompson PD, 1995. Exercise
enhances the maintenance of smoking cessation in women. Addictive Behaviors 20(1): 87-92.
20.
Beim G, Stone DA, 1995. Issues in the female athlete. Sports Medicine 26(3): 443-451.
21.
Jacob’s Institute of Women’s Health, 1998. National Leadership Conference on Physical Activity and Women’s Health.
Women’s Health Issues 8(2): 69-97.
22.
Waller AE, 1989. Identification of Risk Factors for Injury in Adolescent Dancers. Baltimore, MD: Department of
Maternal and Child Health, Johns Hopkins School of Hygiene and Public Health.
23.
Bachrach LK, Guido D, Katzman D, Litt IF, Marcus R, 1990. Decreased bone density in adolescent girls with anorexia
nervosa. Pediatrics 86(3): 440-447.
24.
Clapp CMS, Rokey R, Treadway JL, Carpenter MW, Artal RM, Warrnes C, 1992. Exercise in pregnancy. Medicine and
Science in Sports and Exercise 24(supplement): 294-300.
25.
Sternfeld B, 1997. Physical activity and pregnancy outcome: Review and recommendations. Sports Medicine 23(1): 3347.
26.
Wolfe LA, Ohtake PJ, Mottola MD, McGrath MJ, 1989. Physiological interaction between pregnancy and aerobic exercise. Exercise and Sports Scientific Reviews 17: 295-354.
27.
Dewey KG, Lovelady CA, Nommsen-Rivers LA, McCrory MA, Lonnerdal B, 1994. A randomized study of the effects of
aerobic exercise by lactating women on breast-milk volume and composition. New England Journal of Medicine 330:
449-453.
28.
Ohlin A, Rossner S, 1994. Trends in eating patterns, physical activity and sociodemographic factors in relation to postpartum body weight development. British Journal of Nutrition 71: 457-470.
29.
Marcus B, Fosyth L, 1998. Tailoring interventions to promote physically active lifestyles in women. Women’s Health
Issues 8(2): 104-111.
Effects of Drug and Alcohol Use on Women’s and Perinatal Health
1.
Substance Abuse and Mental Health Services Administration, 1997. Substance Use Among Women in the United States.
Rockville, MD: U.S. Department of Health and Human Services.
2.
Chen K, Kandel DB, 1995. The natural history of drug use from adolescence to the mid-thirties in a general population sample. American Journal of Public Health 85(1): 41-47.
3.
1995. The Women’s Health Data Book: A Profile of Women’s Health in the United States. Washington, DC: The Jacobs
Institute of Women’s Health.
4.
Taeuber CM, 1996. Statistical Handbook on Women in America. Phoenix, AZ: Oryx Press.
87
Charting a Course for the Future of Women’s and Perinatal Health
5.
Resnick MD, Bearman PS, Blum RW, Bauman KE, Harris KM, Jones J, Tabor J, Beuhring T, Sieving RE, Shew M, Ireland
M, Bearinger LH, Udry JR, 1997. Protecting adolescents from harm: Findings from the National Longitudinal Study on
Adolescent Health. JAMA 278(10): 823-832.
6.
Beebe D, 1997. Addictive behaviors. In Rosenfeld JA, ed. Women’s Health in Primary Care. Baltimore, MD: Williams
& Wilkins, 227-240.
7.
Centers for Disease Control and Prevention, 1997. HIV/AIDS Surveillance Report. CDC Surveillance Report 9(1).
8.
Lex BW, 1994. Alcohol and other drug abuse among women. Alcohol Health and Research World (Special Focus:
Women and Alcohol) 18(3): 212-220.
9.
Amaro H, Hardy-Fanta C, 1995. Gender relations in addiction and recovery. Journal of Psychoactive Drugs 27(4):
325-327.
10.
Beckman LJ, 1994. Treatment needs of women with alcohol problems. Alcohol Health and Research World (Special
Focus: Women and Alcohol) 18(3): 206-211.
11.
Wilsnack SC, Wilsnack RW, Hiller-Sturmhofel S, 1994. How women drink: Epidemiology of women’s drinking and
problem drinking. Alcohol Health and Research World (Special Focus: Women and Alcohol) 18(3): 173-181.
12.
Smith BV, Dailard C, 1997. Incarceration. In Allen K, Phillips J, eds. Women’s Health Across the Lifespan: A
Comprehensive Perspective. Philadelphia, PA: Lippincott-Raven Publishers, 464-478.
13.
Allen KM, Feeney E, 1997. Alcohol and other drug use, abuse, and dependence. In Allen KM, Phillips JM, eds.
Women’s Health Across the Lifespan: A Comprehensive Perspective. Philadelphia, PA: Lippincott, 256-288.
14.
Smith-Warner SA, Spiegelman D, Shiaw-Shyuan Y, van den Brandt PA, Folsom AR, Goldbohm A, Graham S, Holmberg
L, Howe G, Marshall JR, Miller AB, Potter JD, Speizer FE, Willet WC, Wolk A, Hunter DJ, 1998. Alcohol and breast
cancer in women: A pooled analysis of cohort studies. JAMA 279(7): 535-540.
15.
Kessler RC, Crum RM, Warner LA, Nelson CB, Schulenberg J, Anthony JC, 1997. Lifetime co-occurrence of DSM-III-R
alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey. Archives of
General Psychiatry 54: 313-321.
16.
Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, Goodwin FK, 1990. Co-morbidity of mental disorders with
alcohol and other drug abuse: Results from the Epidemiologic Catchment Area (ECA) Study. JAMA 264: 2511-2518.
17.
National Institute on Drug Abuse, 1996. National Pregnancy & Health Survey: Drug Use Among Women Delivering Live
Births: 1992. Rockville: National Institute on Drug Abuse, National Institutes of Health, U.S. Department of Health and
Human Services.
18.
1997. Alcohol consumption among pregnant and childbearing-aged women—United States, 1991 and 1995. MMWR
46(16): 346-350.
19.
Lindenberg CS, Alexander EM, Gendrop SC, Nencioli M, Williams DG, 1991. A review of the literature on cocaine
abuse in pregnancy. Nursing Research 40(2): 69-75.
20.
Robins LN, Mills JL, 1993. Effects of in utero exposure to street drugs. American Journal of Public Health 83,
Supplement: 8-32.
21.
Coles C, 1994. Critical periods for prenatal alcohol exposure: Evidence from animal and human studies. Alcohol,
Health & Research World 18(1): 22-29.
22.
Aase JM, 1994. Clinical recognition of FAS: Difficulties of detection and diagnosis. Alcohol Health and Research World
18(1): 5-9.
23.
Gehshan S, 1993. A step toward recovery: Improving access to substance abuse treatment for pregnant and parenting
women. Washington, DC: Southern Regional Project on Infant Mortality.
24.
Association of American Medical Colleges, 1994. Curriculum Directory. Washington, DC: Association of American
Medical Colleges.
25.
Gehshan S, 1995. Missed opportunities for intervening in the lives of pregnant women who are addicted to alcohol
or other drugs. Journal of the American Medical Women’s Association 50(5): 160-163.
26.
Gehshan S, 1995. Missed opportunities for intervening in the lives of pregnant women who are addicted to alcohol or
other drugs. Issue Brief of the Southern Governors’ Association and the Southern Legislative Conference (March): 1-4.
88
Charting a Course for the Future of Women’s and Perinatal Health
27.
Breyel JM, Hill IT, 1993. Creating Systems of Care for Substance-Using Pregnant Women and their Children.
Washington, DC: National Governors’ Association.
28.
Dawson NV, Dadheech G, Speroff T, Smith RL, Schubert DSP, 1992. The effect of patient gender on the prevalence
and recognition of alcoholism on a general medicine inpatient service. Journal of General Internal Medicine 7: 38-45.
29.
Christmas J, Knisley J, Dawson K, Dinsmoor M, Weber S, Schnoll S, 1992. Comparison of questionnaire screening and
urine toxicology for detection of pregnancy complicated by substance use. Obstetrics & Gynecology 80(5): 750-754.
30.
Morse B, Gehshan S, Hutchins E, 1997. Screening for Substance Abuse During Pregnancy: Improving Care, Improving
Health. Arlington, VA: National Center for Education in Maternal and Child Health.
31.
Chavkin W, 1997. Reproductive Health in the Era of Welfare Reform: Presentation at the Department of Maternal and
Child Health Noon Seminar Series, Johns Hopkins University School of Public Health, Baltimore, MD: September 24,
1997.
32.
National Women’s Resource Center, 1997. A Reason for Hope: Substance Abuse Treatment During Pregnancy Has
Long-Term Benefits. Alexandria, VA: National Women’s Resource Center.
33.
Stevens SJ, Arbiter N, 1995. A therapeutic community for substance-abusing pregnant women and women with children: Process and outcome. Journal of Psychoactive Drugs 27(1): 49-56.
34.
Camp JM, Finkelstein N, 1995. Fostering Effective Parenting Skills and Healthy Child Development Within Residential
Substance Abuse Treatment Settings. Boston, MA: Coalition on Addiction, Pregnancy and Parenting.
35.
Bushway D, Heiland L, 1995. Women in treatment for addiction: What’s new in the literature. Alcoholism Treatment
Quarterly 13(4): 83-96.
36.
Finkelstein N, Kennedy C, Thomas K, Kearns M, 1997. Gender-Specific Substance Abuse Treatment. Washington, DC:
The National Women’s Resource Center.
37.
Allen K, 1995. Barriers to treatment for addicted African-American women. Journal of the National Medical Association
87(10): 751-756.
38.
Donaldson SI, Graham JW, Hansen WB, 1994. Testing the generalizability of intervening mechanism theories:
Understanding the effects of adolescent drug use prevention interventions. Journal of Behavioral Medicine 17(2):
195-216.
Effects of Smoking on Women’s and Perinatal Health
1.
1997. Cigarette smoking among adults—United States, 1995. MMWR 46(51): 1217-1220.
2.
Escobedo LG, Reddy M, DuRant RH, 1997. Relationship between cigarette smoking and health risk and problem
behaviors among U.S. adolescents. Archives of Pediatric and Adolescent Medicine 151: 66-71.
3.
Wilson D, Taylor A, Roberts L, 1995. Can we target smoking groups more effectively? A study of male and female
heavy smokers. Preventive Medicine 24: 363-368.
4.
Kristeller JL, Johnson TJ, 1997. Smoking effects and cessation. In Rosenfeld J, ed. Women’s Health In Primary Care.
Baltimore, MD: Williams & Wilkins, 93-116.
5.
Chen Y, Horne SL, Dosman JA, 1993. The influence of smoking cessation on body weight may be temporary.
American Journal of Public Health 83(9): 1330-1332.
6.
Williamson DF, Madans J, Anda RF, Kleinman JC, Giovino GA, Byers T, 1991. Smoking cessation and severity of weight
gain in a national cohort. New England Journal of Medicine 324(11): 739-745.
7.
Manfredi C, Lacey L, Warnecke R, Buis M, 1992. Smoking-related behavior, beliefs, and social environment of young
black women in subsidized public housing in Chicago. American Journal of Public Health 82(2): 267-272.
8.
Shervington DO, 1994. Attitudes and practices of African-American women regarding cigarette smoking: Implications
for interventions. Journal of the National Medical Association 86(5): 337-343.
89
Charting a Course for the Future of Women’s and Perinatal Health
9.
National Center for Health Statistics, 1998. Health, United States, 1998 with Socioeconomic Status and Health
Chartbook. Hyattsville, MD: National Center for Health Statistics.
10.
Pierce JP, Gilpin E, Burns DM, Whalen B, Shopland D, Johnson M, 1991. Does tobacco advertising target young people to start smoking? JAMA 266: 3154-3158.
11.
Carney JK, Hamrell MC, Wargo WE, 1997. No butts about it: Public smoking ends in Vermont. American Journal of
Public Health 87(5): 860-861.
12.
Moore DJ, Williams JD, Qualls WJ, 1996. Target marketing of tobacco and alcohol-related products to ethnic minority groups in the United States. Ethnicity and Disease 6(1-2): 83-98.
13.
Winkelstein W, 1990. Smoking and cervical cancer–current status: A review. American Journal of Epidemiology 131(6):
945-957.
14.
University of Michigan, Institute for Social Research, 1994. Monitoring the Future Project. Ann Arbor, MI: University of
Michigan.
15.
Alameda County Low Birth Weight Study Group, 1990. Cigarette smoking and the risk of low birth weight: A comparison in black and white women. Epidemiology 1(3): 201-205.
16.
Hellerstedt W, Himes J, Story M, Alton I, Edwards L, 1997. The effects of cigarette smoking and gestational weight
change on birth outcomes in obese and normal-weight women. American Journal of Public Health 87(4): 591-596.
17.
Li CQ, Windsor RA, Perkins L, Goldenberg RL, Lowe JB, 1993. The impact of infant birth weight and gestational age
of cotinine-validated smoking reduction during pregnancy. JAMA 269(12): 1519-1524.
18.
Walsh RA, 1994. Effects of maternal smoking on adverse pregnancy outcomes: Examination of the criteria of causation. Human Biology 66(6): 1059-1092.
19.
Baird DD, Wilcox AJ, 1985. Cigarette smoking associated with delayed conception. JAMA 253: 2979-2983.
20.
MacKenzie TD, Bartecchi CE, Schrier RW, 1994. The human costs of tobacco use. The New England Journal of
Medicine 330(14): 975-980.
21.
Baron J, Weiderpass E, 1996. Birth control, hormones, and reproduction. ARHP Clinical Proceedings October 1996: 3-4.
22.
Pirkle JL, Flegal KM, Bernert JT, Brody DJ, Etzel RA, Maurer KR, 1996. Exposure of the U.S. population to environmental
tobacco smoke: The Third National Health and Nutrition Examination Survey, 1988 to 1991. JAMA 275(16): 1233-1240.
23.
Rooney BL, Murray DM, 1996. A meta-analysis of smoking prevention programs after adjustment for errors in the unit of
analysis. Health Education Quarterly 23(1): 48-64.
24.
Worden JK, Flynn BS, Solomon LJ, Secker-Walker RH, Badger GJ, Carpenter JH, 1996. Using mass media to prevent
cigarette smoking among adolescent girls. Health Education Quarterly 23(4): 453-468.
25.
Fiore MC, Bailey WC, Cohen SJ, et al., 1996. Smoking Cessation. Rockville, MD: U.S. Department of Health and Human
Services, Public Health Service, Agency for Health Care Policy and Research.
26.
Fiore MC, Novotny TE, Pierce JP, Giovino GA, Hatziandreu EJ, Newcomb PA, Surawicz TS, Davis RM, 1990. Methods
used to quit smoking in the United States: Do cessation programs help? JAMA 263(20): 2760-2765.
27.
Pirie P, McBride C, Hellerstedt W, Jeffery R, Hatsukami D, Allen S, Lando H, 1992. Smoking cessation in women concerned about weight. American Journal of Public Health 82(9): 1238-1243.
28.
Ockene JK, Kristeller J, Goldberg R, Amick TL, Pekow PS, Hosmer D, Quirk M, Kalan K, 1991. Increasing the efficacy
of physician-delivered smoking interventions: A randomized clinical trial. Journal of General Internal Medicine 6: 1-8.
29.
Lillington L, Royce J, Novak D, Ruvalcaba M, Chlebowski R, 1995. Evaluation of a smoking cessation program for pregnant minority women. Cancer Practice 3(3): 157-163.
90
Charting a Course for the Future of Women’s and Perinatal Health
Volume 1: Concepts, Findings, and Recommendations
ISBN 1-893692-02-7
C
harting
a Course for the
Future of Women’s
and Perinatal Health
Volume 1: Concepts, Findings, and Recommendations
Holly Grason, John Hutchins, and Gillian Silver
Editors
A Collaborative Initiative of the Women’s and Children’s Health Policy Center
Department of Population and Family Health Sciences, The Johns Hopkins
University and the Maternal and Child Health Bureau Health Resources and
Services Administration, U.S. Department of Health and Human Services