The armies mustering for debate over lowering health care costs while raising quality should look first at ways to improve the health of women — and not just when they are pregnant.
When infant deaths soared suddenly in Harlem some years ago, I asked my team at New York City’s Health Department to review every case. We found that many of the mothers had lost several previous pregnancies and that they had chronic or recurrent health problems. But they only received health care when they were pregnant. They got no post-delivery follow-up for their underlying health conditions, so they were doomed to repeated tragedies.
Diabetes and hypertension were among these women’s ailments, and also top the list of problems driving up the costs of health care. Yet health care for American women now focuses mostly on the periods when they are pregnant. And that care comes too late to prevent the risk factors that can lead to pregnancy complications, and it ends too soon. Those complications often foreshadow health problems in later pregnancies or in later life for the woman herself.
For example, many years ago a friend of mine was diagnosed with pregnancy-associated diabetes, which goes away after the baby is born. Hers did, but she developed full-blown diabetes 20 years later. If her prenatal care had been integrated with her general medical care, she would have been monitored and her condition detected early enough to allow easier and less expensive intervention.
Similarly, high blood pressure during pregnancy or delivery of a low-birth-weight infant can signal a woman’s risk of cardiovascular or other health problems later in her life. But these conditions, like my friend’s, will often go untreated until we link reproductive health care with follow-up for health needs over the full lifespan.
More than 62 million American women are now in their reproductive years. The average woman wants only two children, so she will spend five years of her life trying to become pregnant, being pregnant and recovering from pregnancy, and three decades trying to avoid pregnancy.
That means pregnancy-related care alone is not enough. It cannot raise the dismal U.S. maternal mortality rate, for example, which now stands at 15.1 maternal deaths per 100,000 live births, higher than in most other developed countries. And that average hides huge disparities: the overall rate for black women is 3.3 times the rate for white women, and in some states it is six times higher. Disparities also prevail for many other medical problems, which could be tackled earlier if care were integrated across the lifespan.
The pending reform of the American health care system offers the opportunity to create a seamless, lifelong continuum of care for women. Health education, prenatal care, family planning and medical care should be integrated to help women attain good health in their youth, maintain it through their reproductive years and age well. This is so critical to the health of America that the deans of 39 of America’s 50 schools of public health have endorsed our scientific, data-driven report that urged it as a top priority.
But at the moment, one-third of all teenage girls have received zero formal information about contraception. The U.S. teen pregnancy rate is the highest among developed countries, and rising. Rates of unintended pregnancy and abortion are also higher among young and disadvantaged women. Half of all Americans will contract a sexually transmitted infection during their lifetimes, including HIV/AIDS.
Women who have private insurance or work for small firms often have health plans that exclude pregnancy-related care and treatment for complications. While Medicaid expands its eligibility criteria for pregnant women, access to care for these high-risk women ends with the post-partum visit. Moreover, one in every five women now has no health insurance and 40 percent don’t fill prescriptions because they are too expensive. In short, many American women simply do not get the health care they need, especially during their non-pregnant decades.
Polls show that Americans value personal responsibility but expect government to provide the information, services and options to foster it. They believe their personal liberty and responsibility as parents depend upon their ability to decide the number and timing of their children and to make other important life decisions. Reproductive health care must therefore be interwoven with follow-up for health needs in later life.
Health care reform must make quality care universally available, rapid, continuous and affordable. We can lower costs at the same time just by establishing a standard of health for American women that meets their needs. It is time to act.
Chavkin is a professor of Public Health and Obstetrics-Gynecology at Columbia’s Mailman School of Public Health, and recently authored Women’s Health and Health Reform. Copyright (C) 2009 by the American Forum.