Overcoming social and health inequalities among U.S. women of reproductive age—Challenges to the nation's health in the 21st century☆
Introduction
Among the established market economies, the United States (U.S.) has the highest per capita spending on health care; that is 6280 U.S. dollars per person annually totaling $1.9 trillion or 16% of the U.S. Gross Domestic Product (GDP) [1]. The overall health of Americans improved by 17.5% since 1990 [2]; female life expectancy reached an all-time high, and infant mortality, teen pregnancy rates, and pediatric AIDS cases have dropped to an all-time low [3], [4]. Most of the improvements took place in selected fields including infections, and some chronic diseases or risks factors, such as smoking, motor vehicle accidents, and cardiovascular diseases [4], [6].
However, overall health of Americans does not compare favorably to that of many other established market economy countries. Life expectancy of Americans is lower than that in 22 other countries and 4 years behind Japan, whose per capita health spending and GDP share on health is less than half that of the U.S. [4], [5]. Further, improvement in some health indicators appears to have stalled in the past 5 years, especially in the areas of women's health, maternal mortality, and infant morbidity and mortality [2], [3], [4]. Recent improvements in life expectancy in the U.S. took place at faster pace among men than among women; the male to female gap in life expectancy narrowed from 7.8 years in 1979 to 5.3 in 2003 [4], [5]. The U.S. has the highest teen pregnancy rates among established market economies. Infant mortality rate places U.S. the 28th in the world [4], [5]. The difference in the rates of teenage pregnancy and infant mortality between Whites and African-American are more than two-fold [4]. The U.S. ranks 20th in the world in maternal mortality [5]. Given the current status of maternal and infant health, many of the objectives set out in the United States Healthy People 2010, a national blueprint for action, will not be achieved [7].
Past and continued gains in health of Americans are rooted in improving the health of women and children, decreases in the rate of death at older ages, and removal of major threats to health among younger cohorts by shifting to healthier lifestyles [2], [4], [6]. However, such progress will be lost due to factors such as the negative impact of obesity on life expectancy [8]. Protective behaviors, risk factors, and the social environment throughout the course of a woman's life, starting in utero, influence her health, the health of her pregnancy, and the growth and development of her children [9], [10], [11], [12], [13], [14]. In the U.S., despite advancements in prenatal care, reviews of selected risk factors have indicated that a large proportion of women enter pregnancy with pre-existing risks, that pregnancy-related reductions in such risk factors does not occur early in pregnancy, and that post-pregnancy relapse is high [9], [10], [12], [15].
We believe that further improvements in maternal and child health in the U.S., would require reducing several behavioral and macrosocial challenges to health. We suggest here that greater investment in epidemiologic inquiry of such determinants provide a foundation to elevate the dialogue. As a first step along these lines, this paper consolidates new and published nationally representative estimates on the health status and determinants of health among reproductive aged women in a single document. Some determinants of health, including an individual's biologic and genetic profiles, are beyond the scope of the formal medical or public health systems, and they are not considered here.
Section snippets
Data sources
We used national surveys, national vital statistics (www.nchs.cdc.gov), and summary reports from the U.S. Department of Health and Human Services for the most recent years including:
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The U.S. Burden of Disease Report [16]: this is the first attempt to develop health data using the summary measure of mortality and morbidity expressed in disability adjusted life years (DALYS, www.who.int/topics/global_burden_of_disease/en/). It was completed in 2002 using 1996 as the base year.
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The Behavioral Risk
Reproductive status of women
Of the total sample of U.S. women aged 18–44 years in the BRFSS, 4.8% reported that they were pregnant, 3.4% reported that they were planning to become pregnant in the next 12 months, and 12.1% were at risk for a pregnancy. Overall, 8.3% of women aged 15–44 years surveyed in NSFG had a child birth in the past year.
Burden of Disease among women
Chronic diseases contributed to the top nine leading causes of disability-adjusted life years lost (DALYs). Among chronic diseases, mental health disorders were the second leading
Discussion
Nationally representative data reviewed in this paper indicate that a convergence of complex barriers to personal well-being and health care prevent many women of color and low socioeconomic status from enjoying the same health status as their more affluent counterparts. Many indicators discussed in this paper directly affect the health of a newborn and its chances of life survival. Also, steady exposure to the macrosocial challenges predisposes them to development of risks such as obesity or
Conclusions
We have shown that both supply and demand obstacles and macrosocial issues overwhelm the efforts to improve health of women and children in the U.S. As a next step in evidence development, analysis of laboratory data on national prevalence of infectious and environmental challenges among women of childbearing age would be helpful. At the supply level, preconception care is preventive medicine for maternal and child health, and increasing its universal availability should be a national priority.
Contributions
SE conceived the idea, and HA and SP provided overall guidance to the design of the paper. JA conducted statistical analyses of national surveys. RA provided data on quality of care measurements. All authors reviewed, commented, and contributed to the manuscript. JA, SE, and RA are guarantors.
Conflicts of interest
None declared.
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The views expressed in this paper are those of the authors and do not necessarily reflect the views of the US Department of Health and Human Services.