By Susan Kendig, JD, MSN, WHNP-BC, FAANP

As I write this column in mid-May, we are a week past Mother’s Day, and Wo­men’s Health Week has just ended. During the 5th month of the year, healthcare providers (HCPs) and healthcare consumers are bombarded with messaging focused on the importance of women’s health. But then these messages go virtually silent until October—Breast Cancer Awareness Month. During the 10th month of the year, media attention will be drawn to breast cancer, the most frequently diagnosed cancer among women. By the end of October, the wo­m­en’s health voice will once again be stilled until new messaging emerges during February, designated as American Heart Month, when we are encouraged to wear red to symbolize our solidarity in the fight against cardiovascular disease, the No. 1 cause of premature death among women. And so it goes.

On an individual level, as each woman makes her yearly appointment to see her HCP, she also tends to think of her health as an “annual event.” Most women perceive of this annual visit as the time to be screened for breast and cervical cancers and to address their family planning needs, menopausal symptoms, and/or other gynecologic health problems and concerns. But for HCPs who care for female patients, as well as for the patients themselves, women’s health is more than just an annual event.

Reproductive and maternal–child health

National and global statistics underscore the importance of women’s health status in affecting birth outcomes. The United States ranks 31st out of 178 countries on Save the Children’s Mothers’ Index.1 This ranking is based on a composite of five indicators related to maternal well-being: risk of maternal death, under 5-mortality rate (the probability per 1,000 live births that a newborn will die before reaching his or her 5th birthday), expected number of years of formal schooling, gross national income per capita, and wo­m­en’s participation in national government.

Although the U.S. has placed in the top 10 on the Mothers’ Index as recently as 2006, next to Cyprus, our country has fallen farthest from the top. Of the 30 countries now ahead of the U.S. on this index, all but the Republic of Korea have a higher percentage of seats held by women in national government. When women have a voice in policy, issues important to women and children are more likely to emerge as national priorities.1 Worldwide, prematurity is the leading cause of newborn death (birth to 4 weeks) and the second leading cause of death in children younger than 5 years. The U.S. ranks 37th of 165 countries in the number of deaths due to prematurity, placing 6th among the top 10 countries responsible for 60% of the world’s premature births.^1,2

The burden of perinatal morbidity and mortality extends to mothers as well. Since 1990, maternal mortality in this country has nearly doubled. Of approximately 4 million U.S. women each year who give birth, about 52,000 experience severe complications and 500-600 die of these complications. Of these maternal deaths, approximately one-half are preventable. Leading causes of these maternal deaths include thromboemboli, obstetric hemorrhage, and severe hypertension or pre-eclampsia.^3,4

Of the 6.6 million pregnancies that occur in the U.S. each year, 3.4 million (51%) are unintended, occurring disproportionately in non-Hispanic black women, unmarried women, and women with less education and financial stability.^5,6 Intendedness of pregnancy and birth spacing of approximately 2 years are linked to improved pregnancy outcomes. Care before, during, and between pregnancies—including reproductive life planning, optimization of nutrition and exercise, folic acid supplementation, screening for and management of chronic diseases, immunizations, management of infectious diseases, and attention to psychological and behavioral health—contributes to more favorable maternal and child outcomes.²

Sexual/gynecologic health

Sexually transmitted infections (STIs), when untreated, can increase the risk for contracting other STIs, including HIV infection, and lead to other reproductive health problems such as cervical cancer and infertility. STI rates are highest among individuals younger than 25 years, with more than 70% of gonorrhea and chlamydia cases occurring in women in this age group. Gynecologic problems are among the most common health-related complaints for reproductive-aged women. Of the top 10 sites of cancer occurrence in the U.S. population, 3 are woman specific. Lung and bronchial cancers are the leading cause of cancer death among women aged 34-85 years, but breast cancer is more commonly diagnosed and ranks as the second leading cause of cancer death. Recommended screenings can help detect infections that compromise reproductive health, as well as breast, cervical, colorectal, and other cancers, at earlier, more treatable stages.⁷

Women’s health across the lifespan

Both male and female life expectancies have increased over the years, with women now living approximately 4.8 years longer than men. However, female mortality rates have increased in more than 40% of U.S. counties, as compared with an increase in male mortality in only 3.4% of U.S. counties.⁷ Although women’s longevity outpaces that of men in all age groups, the most impoverished 40% of women, relative to the previous generation of women, are seeing life expectancy decline.⁸

While women live longer than men, they are not necessarily healthier.⁹ Women are more likely than men to report activity limitations, with 70% of women older than 65 years reporting such limitations. The most commonly reported causes of activity limitations include back and neck problems, arthritis, depression, anxiety or emotional health problems, bone injuries, and weight problems. Overall, heart disease, cancer, and stroke are the leading causes of death in women, followed by chronic lower respiratory disease and Alzheimer’s disease. Overweight and obesity are key contributors to increased risk for chronic disease, including hypertension, type 2 diabetes mellitus, cardiovascular disease, liver disease, arthritis, cancer, and reproductive health disorders. In addition to chronic disease, women experience higher rates of mental illness than do men,¹⁰ with suicide recognized as one of the top 10 causes of death in women aged 18-64 years. Physical, be­havioral, and mental health problems affecting women require recognition of gender-related differences in symptoms, diagnostic considerations, and treatment decisions.

More than one-third of women have experienced physical violence at the hands of an intimate partner, and 20% of homicides are directly related to intimate partner violence (IPV). IPV, the most common cause of violence-related deaths among 40- to 44-year-olds, is associated with long-term effects on physical, emotional, and sexual health.11 Despite increased attention on the effects of violence against women in their homes, their communities, within the military, and on college campuses, effective screening for such violence remains uneven in healthcare settings. Major HCP organizations, including the National Association of Nurse Practitioners in Women’s Health (NPWH), support universal screening for IPV and other forms of violence against women.

Importance of the well-woman visit

Although the snapshot of women’s health presented in this column may be somewhat disturbing, we can take this opportunity to sharpen our focus and improve the picture now. The well-woman visit (WWV) is designed to make a difference by helping patients identify their personal health risks, access healthcare appropriate to their own needs, and receive support in achieving their goal to be as healthy as possible. The WWV gives women a chance to partner with their HCP in order to do the following:

• Access recommended health screenings and assessments;
• Recognize and address emerging personal and/or family risk factors that may have direct impact on their present and future health status;
• Attend to physical, emotional, behavioral, and environmental factors that affect health and well-being; and
• Identify personal health goals and the strategies to achieve these goals.

These key components of the WWV directly address the many factors affecting women’s reproductive, gynecologic, and sexual health; maternal–child health outcomes; and overall health status from menarche through older adulthood. Under the Affordable Care Act, basic women’s preventive healthcare is covered with no cost-sharing (e.g., co-payments, co-insurance, deductible costs) to the woman. The well-woman preventive care visit is defined as occurring “annually for adult women to obtain the recommended preventive services that are age and developmentally appropriate, including preconception and prenatal care….”¹² In general, the WWV occurs once a year, although the U.S. Department of Health and Human Services recognizes that, depending on a woman’s health status, health needs, and other risk factors, several visits may be needed within a year to obtain all necessary recommended preventive services.¹² The Table lists examples of the types of services that are available as part of the WWV without co-pays, co-insurance, or deductible costs to the woman.^12,13

Conclusion

A woman’s physical and emotional health is influenced by biologic, psychosocial, behavioral, and environmental factors. In addition, the impact of gender differences on the manifestations of chronic disease and mental illness cannot be overlooked. Although events such as Mother’s Day, Women’s Health Week, Breast Cancer Awareness Month, American Heart Month, and other awareness campaigns serve to remind us of the importance of attention to women’s health, they cannot be the sole driver of our focus. Like the components of the WWV, women’s health is addressed and improved in a variety of steps, over time. In order to improve women’s health, regardless of life stage, women’s issues must be a key consideration in every policy decision—education, economics, and, of course, healthcare.

In crafting policy related specifically to women’s health issues, one must consider how such policies…

• Affect the overall health status of women;
• Affect women’s access to and acquisition of high-quality primary and specialty healthcare through the life span—care that is delivered by women’s health-focused HCPs within the context of their patients’ personal, religious, cultural, and family beliefs14; and
• Leverage the expertise of multiple types of gender-focused HCPs, including OB/GYN physicians, women’s health nurse practitioners, certified nurse-midwives and certified midwives, women’s health and perinatal clinical nurse specialists, and other HCPs working in women’s health by convening more comprehensive task forces, commissions, and other panels assembled to inform policy.

Susan Kendig is a teaching professor and WHNP Emphasis Area Coordinator at the University of Missouri-St. Louis, a consultant at Health Policy Advantage, LLC, in St. Louis, Missouri, and Director of Policy for the National Association of Nurse Practitioners in Women’s Health (NPWH). She can be reached at 314-629-2372 or at sue@health
policyadvantage.com.

References
1. Save the Children. State of the World’s Mothers 2014. Westport, CT: Save the Children; 2014.

2. Partnership for Maternal, Newborn & Child Health. Born Too Soon: The Global Action Report on Preterm Birth. Geneva, Switzerland: World Health Organization; 2012.

3. UNFPA. Trends in Maternal Mortality: 1990-2010. Geneva, Switzerland: WHO; 2012.

4. The National Maternal Health Initiative. The Burden of Maternal Mortality and Morbidity in the United States. Rockville, MD: HRSA Maternal Child Health Bureau; 2014.

5. Mosher WD, Jones J, Abma JC. Intended and unintended births in the United States: 1982-2010. Natl Health Stat Rep. 2013;24(55):1-28.

6. Guttmacher Institute. Unintended Pregnancy in the United States. December 2013. www.guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html

7. U.S. Department of Health and Human Services. Health Resources and Services Administration. HRSA Maternal Child Health Bureau. Women’s Health USA 2013. http://mchb.hrsa.gov/whusa13/dl/pdf/hs.pdf

8. Bosworth BP, Burke K. Differential Mortality and Retirement Benefits in the Health and Retirement Study. April 8, 2014. www.brookings.edu/research/papers/2014/04/
differential-mortality-retirement-benefits-bosworth

9. Kaiser Family Foundation. The role of Medicaid and Medicare in women’s health care. JAMA. 2013;309(19):1984. http://jama.jamanetwork.com/article.aspx?articleid=1687586

10. Substance Abuse and Mental Health Services Administration. Results From the 2010 Survey on Drug Use and Health: Mental Health Findings. 2011. www.samhsa.gov/
data/NSDUH/2k10NSDUH/2k10Results.htm

11. Office of the Assistant Secretary for Planning and Evaluation. Screening for Domestic Violence in Health Care Settings. Washington, DC: USDHSS; 2013.

12. U.S. Department of Health and Human Services. Health Resources and Services Administration. Women’s Preventive Services Guidelines. www.hrsa.gov/
womensguidelines/

13. Institute of Medicine. Clinical Services for Women: Closing the Gaps. Washington, DC: National Academies Press; 2011.

14. National Association of Nurse Practitioners in Women’s Health (NPWH). Mission Statement. 2014. www.npwh.org/i4a/pages/index.cfm?pageid=3333