reproductive health disparities: a lifespan approach

Leading The Quest For Health

Reproductive Health Disparities”A Lifespan ApproachKimberly D. Gregory MD, MPHAssociate ProfessorCedars Sinai Medical CenterDavid Geffen School of Medicine &UCLA School of Public Health

KD Gregory 4/06

Reproductive Health Disparities

Why should we care? What is the magnitude of the problem?

Over 90% of US women expect to give birth at least once during their lifetime

4.1 million births in US 60% or more additional pregnancies=tabs, sabs, SB Approximately 6.4 million pregnancy related events Significant issue with regard to health care costs,

health care resources, personal joy/suffering

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Pregnancy is a significant event in a woman’s life and has a profound impact on her health and well-being

Emerging data that the health and well-being of a woman sets the stage for the health and well-being of her offspring, and ultimately her family

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Policy implications Representative indicators specific to women’s health

are widely used to reflect the health of a population (e.g. MMR, IMR)

US has low MMR 11.5/100,000 vs relatively high IMR 6.9/1000 live births—Ranks 25th internationally

Hence, measuring, monitoring and reporting indicators of women’s health should be a national priority

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Women’s Health = Pregnancy Traditional indicators Fertility MMR Onset, adequacy of prenatal

care Fetal and infant mortality Prematurity Low Birth Weight

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Women’s Health = Pregnancy Review recognized disparities in pregnancy and women’s health related to women’s reproductive health conditions

Frame the discussion within the context of a women’s reproductive life span

Provides an opportunity to identify the gaps in knowledge about women’s health outcomes, and to begin to conceptualize potential solutions

Will not address chronic medical conditions

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The Women’s Health Continuum: A Lifespan Approach

Health Maintenance

Post Reproductive

Years

Pre-pregnancyPlanning Pregnancy Postpartum

Newborn (a new life*)

*Fetal origins of adult diseases

PubertyPreconceptionPregnancyPostpartumNewbornInterconceptionMenopausePostreproduction

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Health Maintenance

Post Reproductive

Years




Conditions are not exhaustive or mutually exclusive to anytime periodNo attempt to address chronic diseases

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Puberty

Condition Total White Black Hispanic Asian Other

Puberty (X age, years)

12.7 12.0 --- >white >white

•Trend toward earlier maturation in AA girls as compared with Caucasian girls•AA girls enter puberty 1 to 1.5 yrs earlier (age 8 to 9 years) and start menses 8.5 months earlier (12.1 yrs)•Asians, American Indians comparable (or later) than Caucasian•MA enter puberty at the same time as Caucasian girls, but delayed maturation: reach adult stages later

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Puberty



12.7 12.0 --- >white >white

•Are these “Differences” or “Disparities”?•Environmental factors (lead, nutrition, obesity) influence maturation, and these risk factors are disproportionatelydistributed•Important clinical, educational, and social implications

•Referrals for precocious or delayed puberty•Anticipatory guidance “what to expect when”•Determining time and age appropriate sex education

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Puberty & Preconception



12.7 12.0 --- >white >white

Current Contraception use

46.6 66.6 62.2 58.9 --- ---

STD/PID 8.0 8.0 11.0 --- ---

Teen pregnancy

45.9 28.5 68.3 83.4 18.3 53.8 NA

Abortion 25.6 17.1 52.9 26.1 --- ---

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Preconception

Maternal health during pregnancy is directly related to maternal health prior to pregnancy

Emerging emphasis on preconception care and health maintenance

Women seen by providers during this time should be considered “at risk” for conception

Each visit viewed as contraception or preconception visits— Provide health promotion or primary preventive services— Condoms decrease STD’s (and pregnancy)— Contraception decrease unintended pregnancies (50% of

pregnancies); delay first births, promote birth spacing by at least 2 years

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Preconception

CDC individual level actions by health practitioners to reduce maternal and infant mortality and promote the health of all childbearing-aged women at preconception/interconception visits— Screening for preexisting chronic conditions and health

risks— Counseling about contraception and access to effective

family planning to prevent unintended pregnancy & unnecessary abortion

— Counseling about good nutrition including iron, folic acid— Advise re: regular exercise, ETOH, smoking, drugs

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Health Maintenance

Post Reproductive

Years




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Pregnancy

90% of US women expect to give birth at least once during their lifetime

Good opportunity for health promotion and primary preventive services— May be the only period where some women have coverage— Most women are motivated to change behaviors to optimize

pregnancy outcome— Studies suggest women who seek prenatal care sustain

interactions with the health care system for their newborn (e.g. well baby checks, immunizations, etc)

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Pregnancy


Prenatal care, 1st trimester

83.2 85.0 74.3 74.4

75.6 MA79.1 PR

91.8 CU

77.4 CA

84.0

90.1 JA

87.0 CH

85.0 FIL

82.7 OT79.1 HA

69.3 NA

No PNC 3.7 3.2 6.5 5.9 8.2 6.5

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Pregnancy


Fertility rate (/1000 reproductive age woman)

67.5 58.0 69.3 107.4 69.4 70.4

Birth rate (/1000 population)

3.7 3.2 6.5 5.9 8.2 6.5

•All ethnic groups have higher fertility and birth rates than Caucasians•Changing population demographics makes understanding differences important with regard to prevention/intervention strategies and health care costs and resource utilization

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Pregnancy


Miscarriages (% clinically recognized)

13.8 13.8 13.5 --- --- --

Ectopics 1.3 1.2 1.6 --- --- ---

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Pregnancy


Maternal mortality

11.5 6.0 25.1 10.3 11.3 12.2 NA

Pregnancy comps

GD 2.9

HTN 3.9

2.7

4.2

2.8

2.8

2.9

3.9

--- ---

Cesarean rate

26.1 25.9 27.6 25.2*

36.9 CU

25.0 23.1

Age >35 48.3 48.5 39.4 60.3 73.1 39.8

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Pregnancy


Infertility 15.0 --- --- --- --- ---

Primary Etiology

Ovarian 46.5 14.5

Male fx 24.5 11.5

Other 15.3 3.6

Tubal 13.8 41.0

Unknown 11.0 12.8

Endometrial

4.7 2.6

Sterilized 4.6 25.6

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Health Maintenance

Post Reproductive

Years




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Newborn


Perinatal mortality

--- 1.9 4.7 1.9 --- ---

Fetal deaths

6.6 5.6 12.4 --- --- ---

Neonatal Mortality

4.6 3.8 9.4 3.7 --- ---

Infant Mortality

6.9 5.7 14.1 5.6 5.1 9.0 NA

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Newborn


Infant Mortality

6.9 5.7 14.1 5.6 5.1 9.0 NA

5.5 MA8.1 PR4.3 CU

4.9 CA

3.8 JA3.5 CH

5.9 FIL

5.2 OTH8.7 HA

Diversity among subtypes with Puerto Ricans and Hawaiians having intermediate ratesCompared to AA and Caucasians. Cubans, Japanese, and Chinese = Caucasians

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Newborn


Preterm birth

12.1 11.1 17.5 11.6* 10.4* 13.1 NA

Low Birth Weight

7.8 6.8 13.3 7.8* 7.8* 7.2

VLBW

<1500 g1.5 1.2 3.1 1.5* 1.1* 1.3

IUGR at term

2.9 2.5 5.2 4.0 --- ---

* Variation in rates by different population subtypes

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Health Maintenance

Post Reproductive

Years




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Postpartum & Interconception Health Maintenance

Opportunity for further prevention, screening and interventions Postpartum visit-increased emphasis by ACOG & NCQA Prevention, detection, and early treatment of complications

(e.g. hemorrhage, eclampsia, infection and postpartum depression)

Information and education (child care, breast feeding, nutrition, and contraception

WHO Technical Working Group Postpartum Care suggest one visit isn’t enough and advocates for 6 hours, 6 days, 6 weeks, and 6 mos as critical time when provider visits might be valuable in identifying maternal or neonatal health needs or complications

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Postpartum & Interconception Health Maintenance


Breast-feeding

55.2 59.1 25.1 62.2 --- ---

Depression 8.0

Fibroids (/1000 women)

9.2 8.2 16.9 --- --- ---

Chronic GYN (/1000 women)

97.1

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Interconception Health Maintenance

Gynecologic disorders—Menstrual disorders (most common)—Adnexal conditions (cysts)—Fibroids (20% of women; age, AA)—Endometriosis—Chronic pelvic pain

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Health Maintenance

Post Reproductive

Years




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Post Reproduction and Menopause

Study of Women’s Health Across the Nation (SWAN) —Median age 51.4 (adjusted for smoking education,

marital status, heart disease, parity, race and ethnicity, employment, prior OC’s)

—Current smoking, lower SES associated with earlier menopause

—Parity, prior OC use and Japanese race/ethnicity associated with later menopause

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Significant racial, ethnic, and sociocultural differences in how menopause is experienced and perceived

Japanese and Chinese women reported fewest symptoms

Hispanic women reported the most AA more likely to report hot flashes and vaginal

dryness White women more likely to report urine leakage and

difficulty sleeping Symptoms mediated by BMI, smoking and SES

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Menopause

Median age51.4 51.4 51.4 51.0 51.8 JA

51.4 CH

---

Pelvic prolapse (/1000)

2.1

Incontinence GUI % 59 29 8 14

DI% 15

Caucasians have higher rates of prolapse, incontinence—likely ascertainment Bias; Caucasians more likely to seek treatment for these conditions

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Post Reproduction and MenopauseCondition Total White Black Hispanic Asian Other

Cancer IncidenceBreast 135.8 140.8 120.8 83.6 102.0 54.4

Cervix 9.1 8.8 12.3 16.1 8.6 ---

Ovary 16.7 17.6 11.8 12.4 13.1 ---

Uterus 24.3 25.6 17.3 15.3 18.0 ---

Cancer DeathsBreast 27.2 35.9 17.9 12.5 14.9

Cervix 2.7 5.9 3.7 2.9 2.9

Ovary

Uterus

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So What Can Be Done To Close The Gap?

Healthand

FunctionDisease Health

Care

PhysicalEnvironment

GeneticEndowment

Well-Being Prosperity

IndividualResponse- Behavior- Biology

SocialEnvironment

Dynamic interaction between social and medical forces

Some of the differences can be accounted for by behavior—potentially modifiable

Will require a strategic combination of prevention and intervention across the life span and at multiple levels (individual, family/community, work, public policy) to close the gap in pregnancy and women health outcomes

KD Gregory 4/06

reproductive health disparities: a lifespan approach

Health & Medicine