Health and Health Care Disparities in Women’s Health

1. Health and Health Care Disparities in Women’s Health

2. Health Equity • Attainment of the highest level of health for all people • Requires valuing everyone equally with ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care injustices Healthy People 2020 Equality vs. Equity

3. What are Health Disparities? • Increased burden of an adverse health outcome or health determinant within a specific subset of the the population • Systematic and potentially avoidable differences in health outcomes between different groups of people who have different relative positions in social hierarchies according to wealth, power, or prestige • Imply an inequity or injustice rather that a simple difference What are possible groups in our patient population that may experience health disparities? Braveman Ann Rev Public Health 2006; 1677-94 IOM Report Unequal Treatment, 2003 (Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care)

4. What are Health Care Disparities? • Differences in Quantity and Quality of health care services between groupswith resultant poorer outcome • These are potentially modifiable factors by the health care system • “Health care disparities” typically refer to differences between groups in: • Health insurance coverage • Access (geographic location) and use (perceived discrimination, past discrimination) • Quality of care from providers • Health care disparities contribute to health disparities

5. Root Causes of Disparities - Patient Factors Intrinsically linked to Social Determinants of Health • Cultural differences: preferences, beliefs, mistrust of health providers • Health care literacy • Health behaviors: tobacco, substance use, nutrition, exercise • Allostatic load: physiologic effects of chronic stress as a result of power differential • Patient engagement

6. Root Causes of Disparities - Provider Level Factors • Variation in care for patients: based on perceived differences in wealth, power, prestige • Lack of patient-centered care: recommendations that do not take patient preferences into account • Bias: conscious or unconscious bias • Cultural and linguistic barriers to patient-provider communication • False beliefs about biological differences

7. Root Causes of Disparities – Social and Environmental Factors • The built environment – racial residential segregation: increased advertisement for tobacco, food deserts, lack of safe locations for exercise, increased crime, increased exposure to environmental toxins • Lack of access to healthcare: Non-insured or under insured, lack of providers

8. Why is this important? Scope • Racial and ethnic minorities comprise 38.4% of the population • Projected by 2050 non-Hispanic whites will no longer be majority group Cost • Health disparities are costly in a nation that already spends 17% of GDP on health care • Estimated $265 billion per year spent on race and ethnic health disparities* • ~30% of total direct medical expenditure for Blacks, Hispanics, and Asians are excess costs due to health inequities** • Difference in outcomes in women’s health affect women, families, and communities • Health equity means social justice in health • Health disparities are the metric of health equity *https://obssr.od.nih.gov/health-disparities-are-costly-for-u-s-all-think-about-it-in-april-and-beyond/ **Thomas LaVeist, Darrell Gaskin, and Patrick Richard, The Economic Burden of Health Inequalities in the United States, (Washington, DC: Joint Center for Political and Economic Studies, September 2009)

9. Examples of Health Disparities • Life expectancy: 14.6 y difference between richest 1% and poorest 1% in U.S. Between 2001 and 2014 (Chetty JAMA 2016) • Maternal mortality 3-4x difference between Black and White women • Infant mortality for Black babies twice that of white babies • Breastfeeding Black women 16% less likely to breastfeed and breastfeed for shorter duration • Teen pregnancy rates Black women 15-19 2.5x more likely to have unintended pregnancy

10. Examples of Health Disparities • Breast cancer mortality Black women have lower breast cancer rates but increased risk of death when diagnosed with stage I-II breast cancer HR 2.05 (1.94-2.17) • Preterm birth rate: • Overall 12.8% • Black women 18.4% • White women 11.7% • Hispanic women 12.2% --”Hispanic paradox”: largely same SES as Black but better birth outcomes

11. Examples of Health Care Disparities: Systematic and Individual Bias Sterilization • US history replete with examples of non-consensual sterilization of poor women and women of color in 19th and 20th Century • 150 women in CA prisons were coerced into sterilization from 2006-2010 Contraception • Low income women of color more likely to report being advised to limit childbearing and have IUDs recommended than white women • Blacks more likely than whites to report having been pressured by a clinician to use contraception • In a survey of black women, 28% reported being pressured to start one type of method when they preferred another Dehlindorf: AJOG 2010, Becker: Pespect Sex Reprod Health 2008, Downing: Am J Public Health, 2007, Thorburn: Women Health, 2005

12. Examples of Health Care Disparities: Access to care • Urban vs. Rural access: 49% of 3,143 U.S. counties lack a single OB/Gyn • 179 US hospitals lost obstetrics services between 2004 and 2014 *Rayburn

13. Examples of Health Care Disparities: Quality of Care • Processes of care in Ob/Gyn (including Cesarean delivery and Hysterectomy rates) vary widely across hospitals • Maternal complications can be associated with a physician’s residency training and volume of cases* *Asch, DA et.al. JAMA 2009;302(12):1277-83

14. Examples of quality metrics to monitor disparities in obstetrics Elective delivery Low risk cesarean delivery rates Primary cesarean delivery rates Obstetrical trauma (w/ or w/o instruments) Prophylactic antibiotics at cesarean DVT prophylaxis following cesarean deliveries Administration of antenatal steroids Exclusive breastfeeding rates Severe maternal morbidity and mortality

15. Group Activity Divide into groups of 4, each group member review one of 4 selected papers about health or health care disparities in Ob/Gyn relevant to your population of patients. Identify a faculty “champion” to facilitate the discussions. Spend 10 minutes per paper with focus on: • The disparity • Possible root causes of the disparity • Possible quality metrics that could be used to follow any interventions to promote equity Meet in larger group to debrief the discussion

16. Faculty Panel Discussion • Identify faculty “champions” from clinical divisions • Provide them with training on teaching about SDH and health disparities • Have a panel discussion where each briefly: • Review the literature on disparities in their field • Discusses how SDH and health disparities affect their care of patients

17. Articles describing care for specific groups* • Obese and Overweight Women • Challenges for Overweight and Obese Women. Committee Opinion No. 591. American College of Obstetricians and Gynecologists. ObstetGynecol 2014; 123: 726-30. • Homeless Women • Health care for homeless women. Committee Opinion No. 576. American College of Obstetricians and Gynecologists. ObstetGynecol 2013; 122: 936-40. • Lesbian and Bisexual Women • Health care for lesbians and bisexual women. Committee Opinion No. 525. American College of Obstetricians and Gynecologists. ObstetGynecol 2012; 119: 1077-80. • Undocumented Immigrants • Health care for unauthorized immigrants. Committee Opinion No. 627. American College of Obstetricians and Gynecologists. ObstetGynecol 2015; 125: 755-9. • Rural Women • Health disparities in rural women. Committee Opinion No. 586. American College of Obstetricians and Gynecologists. ObstetGynecol 2014; 123: 384-8. • Women with cognitive disabilities • Female sterilization and cognitive disability in the US 2011-2015. ObstetGynec 2018; 132(3):____ * Please see Disparities Bibliography for additional articles and summaries

18. Specific Medical Conditions in OBGYN* • Sterilization • Access to postpartum sterilization. Committee Opinion No. 530. American College of Obstetricians and Gynecologists. ObstetGynecol 2012; 120:212-15. • Breastfeeding initiation and continuation • Breastfeeding in Underserved Women: Increasing Initiation and Continuation of Breastfeeding. Committee Opinion No. 570. American College of Obstetricians and Gynecologists. ObstetGynecol 2013; 122: 423-8. • Endometrial cancer • Doll K, ,et al. Endometrial cancer disparities: a race-conscious critique of the literature. Am J ObstetGynecol 2017 . • Health care systems • Health care systems for underserved women. Committee Opinion No. 516. American College of Obstetricians and Gynecologists. ObstetGynecol 2012; 119: 206-9. • Zola AR et al. Environmental injustice of beauty: framing chemical exposures from beauty products as a health disparities concern. AJOG October 2017; p418-19 • Benign gynecologic conditions • Jacoby V., et al. Racial and ethnic disparities in benign gynecologic conditions and associated surgeries. Am J Obstet Gynecol. June 2010 • Reproductive outcomes • Zola AR et al. Environmental injustice of beauty: framing chemical exposures from beauty products as a health disparities concern. AJOG October 2017; p418-19 *Please see Disparities Bibliography for additional articles and summaries

19. Additional Resource for application https://safehealthcareforeverywoman.org/patient-safety-bundles/reduction-of-peripartum-racialethnic-disparities/#link_acc-1-5-d • This is AIM bundle with tools to apply in the healthcare setting to evaluate and improve peripartum racial/ethnic disparities

20. Other resources https://safehealthcareforeverywoman.org/wp-content/uploads/2017/11/Reduction-of-Peripartum-Disparities-Bundle.pdf provides checklist for health systems to assess readiness, recognition, response, and reporting and systems learning to increase equity and decrease disparities Environmental Public Health tracking https://ephtracking.cdc.gov/showHome.action National Institute for Minority Health Disparities https://www.nimhd.nih.gov/resources/hd-pulse.html CDC resources https://www.cdc.gov/reproductivehealth/data_stats/index.htm https://www.cdc.gov/nchs/