Our Bodies, Ourselves (162 page)

• The infant death rate among Native Americans and Alaska Natives is almost double and the rate of diabetes is more than twice that for whites. The Pima of Arizona have one of the highest rates of diabetes in the world. Native Americans and Alaska Natives also have disproportionately high death rates from unintentional injuries and suicide.

• Health indicators suggest that Asians and Pacific Islanders, on average, are the healthiest population groups in the United States, although new cases of hepatitis and tuberculosis are higher in these groups than in whites. There is also great diversity within this population group, and health disparities for some specific segments are quite marked. Women of Vietnamese origin, for example, suffer from cervical cancer at nearly five times the rate of white women.

• Tobacco use during pregnancy has declined steadily since 1989 to 10.4 percent in 2007 but varies by race. The rate was highest among Native American/Alaska Native women (24.4 percent) and lowest among Asian/Pacific Islander women (1.5 percent).
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There are also health disparities between women and men. For example, women are more likely than men to experience mental health problems, including depression, anxiety, phobias, and post-traumatic stress disorder. In 2008, 40 percent of Native American/Alaska Native women and women of multiple races reported ever having had depression, followed by 36.5 percent of white women.
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The proportion of military veterans who are female has increased by more than 25 percent in recent years. More than 1.8 million women were veterans as of 2008, and women are expected to account for 9 percent of the veteran population by 2013. This has raised new issues about women's rights and health status. There has been a high rate of reported sexual assaults on women within the military. At the same time, military health care services are prohibited by law from providing abortions. The majority of new female veterans are of childbearing age and are more likely than female veterans of previous eras to obtain their health care from Department of Veterans Affairs (VA) facilities. Women are expected to account for one in seven enrollees in health programs sponsored by the VA over the next ten years.
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Far too often, the care women receive during pregnancy and birth is not based on the most reliable research about what is safe and effective. Unnecessary medical and surgical interventions that don't improve outcomes are overused, particularly elective labor inductions and cesarean sections, and practices known to improve maternal and child outcomes and maternal satisfaction are underused. (For more information, see
Chapter 15
, “Pregnancy and Preparing for Birth.”)

According to Amnesty International, the United States spends $86 billion a year on hospital charges related to pregnancy and childbirth, the highest of any single area of medicine. Yet the United States ranks behind forty other countries in a woman's lifetime risk of dying from pregnancy-related complications.
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In 2007, 548 women died in childbirth in the United States,
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but complications and near misses push the consequences much higher. According to an Amnesty International report on maternal health:

[The] likelihood of a woman dying in childbirth in the USA is five times greater than in Greece, four times greater than in Germany, and three times greater than in Spain. More than two women die every day in the USA from pregnancy-related causes. Maternal deaths are only the tip of the iceberg. Severe complications that result in a woman nearly dying, known as a “near miss,” increased by 25 percent between 1998 and 2005. During 2004 and 2005, 68,433 women nearly died in childbirth in the USA. More than a third of all women who give birth in the USA—1.7 million women each year—experience some type of complication that has an adverse effect on their health.
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A combination of lack of affordable, accessible health insurance, lack of comprehensive coverage in some health insurance policies, gaps in access to Medicaid and related programs, and social and economic conditions and citizenship status all contribute to high rates of maternal complications. African-American women are nearly four times more likely to die from pregnancy-related complications than white women; these rates and disparities have not improved in twenty years. According to Amnesty International:

In high-risk pregnancies, the disparities are even greater, with African-American women 5.6 times more likely to die than white women. Among women diagnosed with pregnancy-induced hypertension (eclampsia and pre-eclampsia), African-American and Latina women were 9.9 and 7.9 times more likely to die than white women with the same complications.

Discrimination profoundly affects a woman's chances of being healthy in the first place. Women of color are less likely to begin their pregnancies in good health for a range of reasons including lack of access to primary health care services. They are also less likely to have access to adequate maternal health care services. Compared with white women, Native American and Alaska Native women are 3.6 times, African-American women 2.6 times, and Latina women 2.5 times as likely to receive late or no prenatal care. They are also more likely to experience poorer quality of care, discrimination, or culturally inappropriate treatment.
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Melissa Gilliam, an ob-gyn and former chair of the board of the Guttmacher Institute, adds to these factors too few educational and professional opportunities for minority women; unequal access to safe, clean neighborhoods; and, for some African Americans, a lingering mistrust of the medical community.
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Preterm birth, birth before thirty-seven weeks gestation, is the leading cause of newborn death, and very premature babies (before thirty-two weeks) who survive may suffer lifelong consequences, including cerebral palsy, blindness, and other chronic conditions.
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The rate of preterm births in the United States improved slightly in 2008, declining to about 12.3 percent, or 523,033 infants.
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Preterm birth rates were highest for black infants (18.4 percent), followed by Native Americans (14.2 percent), Hispanics (12.2 percent), whites (11.6 percent), and Asians (10.8 percent).

The causes of preterm births appear to be multifaceted and resist direct or routine medical interventions. According to the March of Dimes, about half of premature births result from spontaneous preterm labor, the causes of which are unknown. One-third of premature births can be attributed to an infection in a woman's uterus, which may not have presented any symptoms. Research is being done to determine if there's a genetic link—if women who were born prematurely may be more likely to deliver early themselves.
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Research by physician Michael Lu and others links intergenerational poverty, racism, and social isolation to chronic stress that triggers changes in women's immune and vascular systems, making them more vulnerable to having a preterm birth.
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Organizations such as HealthConnect One (healthconnectone.org) in Chicago are working to reduce disparities by training and providing assistance to frontline community organizations. HealthConnect One's community-based doula program, for example, focuses on connecting underserved women to women in their community who are specially trained to provide support during pregnancy, birth, and the early months of parenting. Also encouraging is the Centering Pregnancy program
in Connecticut, part of the Centering Healthcare Institute (centeringhealthcare.org), which promotes a model of group care that integrates health assessment, education, and support. Both of these peer-to-peer programs are exemplars for improving and promoting women's health.

Owing in part to the politicization of reproductive health care, the rates of unintended pregnancies and sexually transmitted infections are also higher in the United States than in virtually every other country with comparable economic and social indicators.

The teen pregnancy rate in the United States dropped 41 percent between 1990 and 2005 (from 116 pregnancies per 1,000 women age fifteen to nineteen to 69.5 per 1,000)—the result of more and better contraceptive use among sexually active teens. Teen birth and abortion rates also declined, with births dropping 35 percent between 1991 and 2005 and teen abortion declining 56 percent between its peak in 1988 and 2005.
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Political efforts to limit access to contraceptive methods during the two terms of President George W. Bush led to temporary reversals in these trends. There was heavy investment in sex education programs aimed exclusively at promoting abstinence and prohibited by law from discussing the benefits of contraception. Teens' use of contraceptives declined.
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In 2006, there was a rise in teen pregnancies (ages fifteen to nineteen) to 71.5 pregnancies per 1,000 women. These trends included sharp reversals in declining teen pregnancy rates among African-American teens, Latina teens, and non-Hispanic whites.

As a result of the rise in teenage birth rates, many states began to reconsider abstinence-only curricula. In 2007, for example, after receiving nearly $9 million in federal funds for abstinence-only programs, Ohio embraced more comprehensive sex education, becoming the eighth state to reject federal funding dedicated to abstinence-only programs. A congressional investigation found that much of the federally approved abstinence-only curricula included false, misleading, or distorted information about reproductive health.
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Teen births declined again in 2009, perhaps in response to new policies and to the recession.
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However, the new majority in the U.S. House of Representatives of 2011 has announced its intention to revert to the Bush policies.

Another severe example of politics trumping science during the Bush administration was the FDA's refusal to approve over-the-counter (OTC) sale of the emergency contraceptive Plan B, despite encouragement from medical advisory experts. Two FDA officials resigned in protest in 2005 after the FDA announced it would postpone the approval of OTC Plan B indefinitely. One year later, the FDA ruled that Plan B could be sold without a prescription, but only for women over age eighteen. In 2010, the U.S. District Court for the Eastern District of New York ruled that the FDA must lower the OTC cutoff to seventeen and urged the FDA to do away with age restrictions entirely. The government opted not to appeal the decision, thus allowing the cutoff age to be reduced to seventeen in 2011.

Starting in 2010, the U.S. Department of Health and Human Services, under a new administration, divided a five-year, $375 million grant among twenty-eight programs that have been proved to lower pregnancy rates. While some programs are involved in condom distribution,
others aim to boost teens' scholastic performance and increase their involvement in extracurricular and community activities.

Sexually transmitted infections among teens and young adults in the United States are at epidemic proportions. Young people age fifteen to twenty-four account for nearly half of the 19 million new cases of all STIs in the United States each year.
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,
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Most STIs disproportionately affect women, especially young women, and the burden is most severe among young women of color.

Researchers have found that women in low-income, racially segregated communities with high incarceration rates and limited health care access are most at risk, even when they participate in low-risk sexual activities
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(see
“Who Gets Infected?”
for further discussion). Chlamydia, the most commonly reported infectious disease in the United States,
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is also one of the most underdiagnosed and can lead to pelvic inflammatory disease and infertility. Expanded screening and treatment for this STI would benefit many women.

Human papillomavirus (HPV) infections are the most commonly spread infections. While most HPV infections clear up on their own, some types of the virus can lead to cervical cancer. Pap tests are a highly effective method for early detection of precancer and cervical cancer, but lower-income women have worse access to this common screening test. According to the CDC, in 2008, 69 percent of women defined as poor by federal standards had a Pap test within the previous three years, compared with 79 percent of women whose income was at least twice the poverty level.

New vaccines can prevent infection by the most common types of HPV if girls obtain the shots before they are sexually active. The District of Columbia and dozens of states—many of which have been lobbied by vaccine makers to expand vaccination requirements—have introduced legislation to require, fund, or educate the public about the HPV vaccine.
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However, since 30 percent of infections are now caused by virus types for which the HPV vaccines do not provide protection, universal access to Pap tests remains critically important. Unfortunately, many girls in underserved communities (where HPV infection rates are often high) have less access to both the Pap test and the HPV vaccine.

For example, as of September 2009, when the CDC released its first state-level statistics for the HPV vaccine Gardasil, only 15.8 percent of girls in the relatively poor state of Mississippi had received the vaccine, compared with 54.7 percent of girls in the relatively wealthy state of Rhode Island. Partly because of greater access to Pap testing, the cervical cancer mortality rate in Rhode Island was already 50 percent lower than in Mississippi—which means the girls in Rhode Island are at much lower risk of contracting HPV to start with.
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