Leading The Quest For Health 

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. 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 KD Gregory 4/06

3. 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 KD Gregory 4/06

4. 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 25th internationally • Hence, measuring, monitoring and reporting indicators of women’s health should be a national priority KD Gregory 4/06

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

6. 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 Reproductive Health Disparities KD Gregory 4/06

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

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

9. Puberty • 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 KD Gregory 4/06

10. Puberty • 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 KD Gregory 4/06

11. Puberty & Preconception KD Gregory 4/06

12. 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 KD Gregory 4/06

13. 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 KD Gregory 4/06

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

15. 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) KD Gregory 4/06

16. Pregnancy KD Gregory 4/06

17. Pregnancy • 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 KD Gregory 4/06

18. Pregnancy KD Gregory 4/06

19. Pregnancy KD Gregory 4/06

20. Pregnancy KD Gregory 4/06

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

22. Newborn KD Gregory 4/06

23. Newborn Diversity among subtypes with Puerto Ricans and Hawaiians having intermediate rates Compared to AA and Caucasians. Cubans, Japanese, and Chinese = Caucasians KD Gregory 4/06

24. Newborn * Variation in rates by different population subtypes KD Gregory 4/06

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

26. 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 KD Gregory 4/06

27. Postpartum & Interconception Health Maintenance KD Gregory 4/06

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

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

30. 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 KD Gregory 4/06

31. 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 KD Gregory 4/06

32. Post Reproduction and Menopause Caucasians have higher rates of prolapse, incontinence—likely ascertainment Bias; Caucasians more likely to seek treatment for these conditions KD Gregory 4/06

33. Post Reproduction and Menopause KD Gregory 4/06

34. Physical Environment Genetic Endowment Social Environment Individual Response - Behavior - Biology Health and Function Disease Health Care Well-Being Prosperity So What Can Be Done To Close The Gap? • 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

35. Enquiring minds want to know... "would we know more if men got pregnant?" KD Gregory 4/06