1. Leading The Quest For Health  Reproductive Health Disparities” A Lifespan Approach Kimberly D. Gregory MD, MPH Associate Professor Cedars Sinai Medical Center David Geffen School of Medicine & UCLA School of Public Health

2. KD Gregory 4/06 Reproductive Health Disparities  Why should we care? What is the magnitude of the problem?  Over 90% of US women expect to give birth at least once during their lifetime  4.1 million births in US  60% or more additional pregnancies=tabs, sabs, SB  Approximately 6.4 million pregnancy related events  Significant issue with regard to health care costs, health care resources, personal joy/suffering

3. KD Gregory 4/06 Reproductive Health Disparities  Pregnancy is a significant event in a woman’s life and has a profound impact on her health and well-being  Emerging data that the health and well-being of a woman sets the stage for the health and well-being of her offspring, and ultimately her family

4. KD Gregory 4/06 Reproductive Health Disparities  Policy implications  Representative indicators specific to women’s health are widely used to reflect the health of a population (e.g. MMR, IMR)  US has low MMR 11.5/100,000 vs relatively high IMR 6.9/1000 live births —Ranks 25 th internationally  Hence, measuring, monitoring and reporting indicators of women’s health should be a national priority

5. KD Gregory 4/06 Reproductive Health Disparities Women’s Health = Pregnancy  Traditional indicators  Fertility  MMR  Onset, adequacy of prenatal care  Fetal and infant mortality  Prematurity  Low Birth Weight

6. KD Gregory 4/06 Reproductive Health Disparities Women’s Health = Pregnancy  Review recognized disparities in pregnancy and women’s health related to women’s reproductive health conditions  Frame the discussion within the context of a women’s reproductive life span  Provides an opportunity to identify the gaps in knowledge about women’s health outcomes, and to begin to conceptualize potential solutions  Will not address chronic medical conditions

7. KD Gregory 4/06 The Women’s Health Continuum: A Lifespan Approach Health Maintenance Post Reproductive Years Pre-pregnancy Planning Pregnancy Postpartum Newborn (a new life*) * Fetal origins of adult diseases Puberty Preconception Pregnancy Postpartum Newborn Interconception Menopause Postreproduction

8. KD Gregory 4/06 The Women’s Health Continuum: A Lifespan Approach Health Maintenance Post Reproductive Years Pre-pregnancy Planning Pregnancy Postpartum Newborn (a new life*) * Fetal origins of adult diseases Conditions are not exhaustive or mutually exclusive to any time period No attempt to address chronic diseases

9. KD Gregory 4/06 Puberty ConditionTotalWhiteBlackHispanicAsianOther Puberty (X age, years) 12.712.0--->white Trend toward earlier maturation in AA girls as compared with Caucasian girls AA girls enter puberty 1 to 1.5 yrs earlier (age 8 to 9 years) and start menses 8.5 months earlier (12.1 yrs) Asians, American Indians comparable (or later) than Caucasian MA enter puberty at the same time as Caucasian girls, but delayed maturation: reach adult stages later

10. KD Gregory 4/06 Puberty ConditionTotalWhiteBlackHispanicAsianOther Puberty (X age, years) 12.712.0--->white Are these “Differences” or “Disparities”? Environmental factors (lead, nutrition, obesity) influence maturation, and these risk factors are disproportionately distributed Important clinical, educational, and social implications Referrals for precocious or delayed puberty Anticipatory guidance “what to expect when” Determining time and age appropriate sex education

11. KD Gregory 4/06 Puberty & Preconception ConditionTotalWhiteBlackHispanicAsianOther Puberty (X age, years) 12.712.0--->white Current Contracep tion use 46.666.662.258.9--- STD/PID 8.0 11.0--- Teen pregnancy 45.928.568.383.418.3 53.8 NA Abortion 25.617.152.926.1---

12. KD Gregory 4/06 Preconception  Maternal health during pregnancy is directly related to maternal health prior to pregnancy  Emerging emphasis on preconception care and health maintenance  Women seen by providers during this time should be considered “at risk” for conception  Each visit viewed as contraception or preconception visits —Provide health promotion or primary preventive services —Condoms decrease STD’s (and pregnancy) —Contraception decrease unintended pregnancies (50% of pregnancies); delay first births, promote birth spacing by at least 2 years

13. KD Gregory 4/06 Preconception  CDC individual level actions by health practitioners to reduce maternal and infant mortality and promote the health of all childbearing-aged women at preconception/interconception visits —Screening for preexisting chronic conditions and health risks —Counseling about contraception and access to effective family planning to prevent unintended pregnancy & unnecessary abortion —Counseling about good nutrition including iron, folic acid —Advise re: regular exercise, ETOH, smoking, drugs

14. KD Gregory 4/06 The Women’s Health Continuum: A Lifespan Approach Health Maintenance Post Reproductive Years Pre-pregnancy Planning Pregnancy Postpartum Newborn (a new life*) * Fetal origins of adult diseases

15. KD Gregory 4/06 Pregnancy  90% of US women expect to give birth at least once during their lifetime  Good opportunity for health promotion and primary preventive services —May be the only period where some women have coverage —Most women are motivated to change behaviors to optimize pregnancy outcome —Studies suggest women who seek prenatal care sustain interactions with the health care system for their newborn (e.g. well baby checks, immunizations, etc)

16. KD Gregory 4/06 Pregnancy ConditionTotalWhiteBlackHispanicAsianOther Prenatal care, 1 st trimester 83.285.0 74.374.4 75.6 MA 79.1 PR 91.8 CU 77.4 CA 84.0 90.1 JA 87.0 CH 85.0 FIL 82.7 OT 79.1 HA 69.3 NA No PNC 3.73.26.55.98.26.5

17. KD Gregory 4/06 Pregnancy ConditionTotalWhiteBlackHispanicAsianOther Fertility rate (/1000 reproductive age woman) 67.558.069.3107.469.470.4 Birth rate (/1000 population) 3.73.26.55.98.26.5 All ethnic groups have higher fertility and birth rates than Caucasians Changing population demographics makes understanding differences important with regard to prevention/intervention strategies and health care costs and resource utilization

18. KD Gregory 4/06 Pregnancy ConditionTotalWhiteBlackHispanicAsianOther Miscarriages (% clinically recognized) 13.8 13.5--- -- Ectopics 1.31.21.6---

19. KD Gregory 4/06 Pregnancy ConditionTotalWhiteBlackHispanicAsianOther Maternal mortality 11.56.025.110.311.312.2 NA Pregnancy comps GD 2.9 HTN 3.9 2.7 4.2 2.8 2.9 3.9 --- Cesarean rate 26.125.927.625.2* 36.9 CU 25.023.1 Age >35 48.348.539.460.373.139.8

20. KD Gregory 4/06 Pregnancy ConditionTotalWhiteBlackHispanicAsianOther Infertility 15.0 --- Primary Etiology Ovarian 46.514.5 Male fx 24.511.5 Other 15.33.6 Tubal 13.841.0 Unknown 11.012.8 Endometr ial 4.72.6 Sterilized 4.625.6

21. KD Gregory 4/06 The Women’s Health Continuum: A Lifespan Approach Health Maintenance Post Reproductive Years Pre-pregnancy Planning Pregnancy Postpartum Newborn (a new life*) * Fetal origins of adult diseases

22. KD Gregory 4/06 Newborn ConditionTotalWhiteBlackHispanicAsianOther Perinatal mortality ---1.94.71.9--- Fetal deaths 6.65.612.4--- Neonatal Mortality 4.63.89.43.7--- Infant Mortality 6.95.714.15.65.19.0 NA

23. KD Gregory 4/06 Newborn ConditionTotalWhiteBlackHispanicAsianOther Infant Mortality 6.9  5.7 14.15.65.19.0 NA 5.5 MA 8.1 PR  4.3 CU 4.9 CA  3.8 JA  3.5 CH 5.9 FIL 5.2 OTH 8.7 HA Diversity among subtypes with Puerto Ricans and Hawaiians having intermediate rates Compared to AA and Caucasians. Cubans, Japanese, and Chinese = Caucasians

24. KD Gregory 4/06 Newborn ConditionTotalWhiteBlackHispanicAsianOther Preterm birth 12.111.117.511.6*10.4*13.1 NA Low Birth Weight 7.86.813.37.8* 7.2 VLBW <1500 g 1.51.23.11.5*1.1*1.3 IUGR at term 2.92.55.24.0--- * Variation in rates by different population subtypes

25. KD Gregory 4/06 The Women’s Health Continuum: A Lifespan Approach Health Maintenance Post Reproductive Years Pre-pregnancy Planning Pregnancy Postpartum Newborn (a new life*) * Fetal origins of adult diseases

26. KD Gregory 4/06 Postpartum & Interconception Health Maintenance  Opportunity for further prevention, screening and interventions  Postpartum visit-increased emphasis by ACOG & NCQA  Prevention, detection, and early treatment of complications (e.g. hemorrhage, eclampsia, infection and postpartum depression)  Information and education (child care, breast feeding, nutrition, and contraception  WHO Technical Working Group Postpartum Care suggest one visit isn’t enough and advocates for 6 hours, 6 days, 6 weeks, and 6 mos as critical time when provider visits might be valuable in identifying maternal or neonatal health needs or complications

27. KD Gregory 4/06 Postpartum & Interconception Health Maintenance ConditionTotalWhiteBlackHispanicAsianOther Breast- feeding 55.259.125.162.2--- Depression 8.0 Fibroids (/1000 women) 9.28.216.9--- Chronic GYN (/1000 women) 97.1

28. KD Gregory 4/06 Interconception Health Maintenance  Gynecologic disorders —Menstrual disorders (most common) —Adnexal conditions (cysts) —Fibroids (20% of women; age, AA) —Endometriosis —Chronic pelvic pain

29. KD Gregory 4/06 The Women’s Health Continuum: A Lifespan Approach Health Maintenance Post Reproductive Years Pre-pregnancy Planning Pregnancy Postpartum Newborn (a new life*) * Fetal origins of adult diseases

30. KD Gregory 4/06 Post Reproduction and Menopause  Study of Women’s Health Across the Nation (SWAN) —Median age 51.4 (adjusted for smoking education, marital status, heart disease, parity, race and ethnicity, employment, prior OC’s) —Current smoking, lower SES associated with earlier menopause —Parity, prior OC use and Japanese race/ethnicity associated with later menopause

31. KD Gregory 4/06 Post Reproduction and Menopause  Significant racial, ethnic, and sociocultural differences in how menopause is experienced and perceived  Japanese and Chinese women reported fewest symptoms  Hispanic women reported the most  AA more likely to report hot flashes and vaginal dryness  White women more likely to report urine leakage and difficulty sleeping  Symptoms mediated by BMI, smoking and SES

32. KD Gregory 4/06 Post Reproduction and Menopause ConditionTotalWhiteBlackHispanicAsianOther Menopause Median age 51.4 51.051.8 JA 51.4 CH --- Pelvic prolapse (/1000) 2.1 Incontinence GUI %5929814 DI%15 Caucasians have higher rates of prolapse, incontinence—likely ascertainment Bias; Caucasians more likely to seek treatment for these conditions

33. KD Gregory 4/06 Post Reproduction and Menopause ConditionTotalWhiteBlackHispanicAsianOther Cancer Incidence Breast135.8140.8120.883.6102.054.4 Cervix9.18.812.316.18.6--- Ovary16.717.611.812.413.1--- Uterus24.325.617.315.318.0--- Cancer Deaths Breast27.235.917.912.514.9 Cervix2.75.93.72.9 Ovary Uterus

34. KD Gregory 4/06 So What Can Be Done To Close The Gap? Health and Function Disease Health Care Physical Environment Genetic Endowment Well-BeingProsperity Individual Response - Behavior - Biology Social Environment  Dynamic interaction between social and medical forces  Some of the differences can be accounted for by behavior—potentially modifiable  Will require a strategic combination of prevention and intervention across the life span and at multiple levels (individual, family/community, work, public policy) to close the gap in pregnancy and women health outcomes

35. KD Gregory 4/06