1. Poverty and politics: their impact on women's reproductive health outcomes over time By Richard M. Kimball MSN/MPH, PHCNS-BC, PhD, RN APHA – New Orleans ; Tuesday 18 Nov. 2014 Session 4169.0 Abortion and Reproductive Rights: History and Current Politics

2. Presenter Disclosures (1)The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Richard M. Kimball No relationships to disclose

3. Policy Backdrop US health care $7771 per capita 39 th in world Life Expectancy = 78 IMR = 6.6 Teen Births = 41.5 Abortions = 19.6 Social Determinants of Health Income Inequality Poverty Rates Polarized elections Religious orthodoxy

4. Navarro et al. 2006 Link Politics & Policy with Health Outcomes

9. Red vs. Blue States 2004 Election2008 Election BlueRedBlueRed States19312822 Women's Reproductive Health Outcomes IMR6.057.356.217.23 Teen Births26.646.235.049.5 Abortions20.612.019.810.3 Social Determinants of Health Poverty10.5%13.0%11.4%13.7% Religiosity*47.8%60.4%50.2%62.5%

10. Presidential Election 2004

11. Presidential Election 2008

12. Purple States

20. How do states compare? IMRTeen BirthsReligionPovertyAbortionElection State20042008200420082004/08200420082004200820042008 New Hampshire5.633.8718.219.836%7.6%7.5%11.712.3Blue Massachusetts4.805.0422.320.140%9.2%10.1%19.918.3Blue California5.165.1139.538.448%13.3%13.4%27.127.6Blue Virginia7.356.8835.233.559%9.5%10.3%16.517.6RedBlue Texas6.286.1762.663.467%16.6%16.0%17.316.5Red Louisiana10.319.0456.254.173%19.4%17.4%11.716.1Red Mississippi9.909.9561.965.782%21.6%21.4%4.94.6Red

21. Correlations- 2004/2008 2008 Health OutcomesPovertyReligiosity2008 Election IMR0.490.700.39 Teen Births0.720.700.59 Abortion-0.16*-0.25*-0.57 *N OT SS Cohen, effect sizes = 0.1 small, 0.3 medium, 0.5 large 2004 Health OutcomesPovertyReligiosity2004 Election IMR0.500.710.44 Teen Births0.720.710.68 Abortion-0.18*-0.29-0.51

22. Regression Results- 2004 IMRβ Coef.SEtp-value95% Conf.IntervalR 2 =0.52 Religion 0.090.024.370.000.050.13 Poverty 0.050.070.730.47-0.080.18 Election '04 0.100.370.270.79-0.650.86 Intercept 1.440.871.670.10-0.303.19 Teen Birthsβ Coef.SEtp-value95% Conf.IntervalR 2 =0.72 Religion0.260.122.090.040.010.50 Poverty1.700.414.150.000.882.52 Election '049.092.343.880.004.3813.81 Intercept-0.455.42-0.080.93-11.3510.45 Abortionβ Coef.SEtp-value95% Conf.IntervalR 2 =0.27 Religion-0.020.14-0.180.86-0.300.25 Poverty0.160.450.350.73-0.751.06 Election '04-8.662.58-3.360.00-13.85-3.47 Intercept20.075.963.370.008.0732.08

23. Regression Results- 2008 IMRβ Coef.SEtp-value95% Conf.IntervalR 2 =0.50 Religion 0.080.024.490.000.040.11 Poverty 0.06 1.050.30-0.060.18 Election '08 -0.080.33-0.250.80-0.760.59 Intercept 1.600.831.920.06-0.083.27 Teen Birthsβ Coef.SEtp-value95% Conf.IntervalR 2 =0.67 Religion0.350.132.650.010.090.62 Poverty1.890.444.290.001.002.77 Election '085.822.552.280.030.6910.96 Intercept-4.236.34-0.670.51-16.998.54 Abortionβ Coef.SEtp-value95% Conf.IntervalR 2 =0.33 Religion0.060.130.480.64-0.200.32 Poverty0.140.430.330.75-0.721.00 Election '08-10.642.48-4.300.00-15.62-5.65 Intercept15.146.162.460.022.7427.54

24. Interpreting the Results: IMR As Religion scores increase by 1%, IMR is predicted to increase by 0.08-0.09 per 1,000 (or 1.2-1.3% at the mean in 2004/2008). That is a predicted 3.7-4.2 per 1,000 increase in IMR from the least religious to the most religious states. 50-52% of the variance in IMR among the states explained by the models. StateReligionIMR 2008 New Hampshire36% Least3.9 Lowest Mississippi82% Most10.0 Highest StateReligion2008 Vermont36% Least4.4 Lowest Louisiana73% High10.3 Highest

25. Teen Births As Religion scores increase by 1%, the teen birth rate is predicted to increase by 0.26/0.35 per 1,000 That is a predicted 12/16 per 1,000 increase in teen births from the least religious to the most religious states. As poverty rates increase by 1%, the teen birth rate is predicted to increase by 1.7/1.9 per 1,000 That is a predicted 24/26 per 1,000 increase in teen births from the lowest to highest poverty states. Voting “Red” in ‘04/‘08 Presidential election, predicts a 9.1/5.8 per 1,000 increase in teen births 67-72% of the variance in teen births explained by models. StateElection ‘08Poverty 2008Teen Birth Rate 2008 New HampshireBlue7.5% Lowest19.8/1,000 Lowest MississippiRed21.4% Highest65.7/1,000 Highest

26. Abortion For those states voting “Red” in the ’04/’08 Presidential election, predicts a 8.7/10.6 per 1,000 decrease in abortions 27/33% of the variance in abortion explained by the model. StateElection ’08Abortion ‘08 DelawareBlue40.0/1,000 Highest WyomingRed0.9/1,000 Lowest

27. Limitations on Women’s reproductive rights Limiting women’s reproductive rights (for many reasons it seems) results in worse health outcomes Poverty/Education – teen births Religiosity – IMR, teen births Politics – abortions, teen births

28. Kerala vs. other Indian States 1950s Poor women’s reproductive health outcomes High poverty Orthodox religious caste system 2000s Better IMR, literacy, outcomes than all of India Dedicated political leaders willing to prioritize public health- people centered social & economic outcomes

29. What can we do? Advocate for FREE & open access to contraception Universal access to education Access to abortion Vote for policy-makers who believe in science and public health Work with religious communities to improve care, access & outcomes. Concentrate on Federal/State/Local policy makers- many decisions on local/state levels

30. HEALTHOGRAPHY Place does matter- but it can change Continue research on the social determinants of health Use GIS – map it! Advocate for change Champion women’s reproductive health rights

31. Thank You! GIS Mapping Contributor Michael Wissner, M.S. M.S. Geography and Environmental Systems, University of Maryland, Baltimore County RPCV Peru ‘05- ‘07 Fellow Alumni – Sargent Shriver Peace Worker