Friday, September 16, 2011

Unintended pregnancy and health disparities

In "Health in All" policies to eliminate health disparities are a real answer, August 18, 2011, I discussed the work of Steven Woolf, MD, as it relates to health disparities. The major point of that piece is that the health and mortality differences between groups, particularly racial groups, in the United States accounts for an enormous number of excess deaths. If that gap were closed, and everyone in the US had the same age-adjusted death rate as whites, the number of lives saved would far exceed those saved by all medical care. Indeed, it would far exceed the number of lives saved even by public health interventions, at least as narrowly construed. Many of the social interventions that Woolf and colleagues indicate would be necessary to decrease disparities could be thought of as “public health” in a broader sense, because they would improve the public’s health, but in general eliminating poverty and raising educational levels are not part of the narrower public health construct.

In “Unintended pregnancy in the United States: incidence and disparities, 2006”, published on-line-before-print in Contraception, Lawrence B. Finer and Mia R. Zolna of the Guttmacher Institute report on the disparities in a particular group, women of reproductive age, in relation to unintended pregnancy. They combined data from several sources, “…on women's pregnancy intentions from the 2006–2008 and 2002 National Survey of Family Growth… a 2008 national survey of abortion patients and data on births from the National Center for Health Statistics, induced abortions from a national abortion provider census, miscarriages estimated from the National Survey of Family Growth and population data from the US  Census Bureau,” to assess rates of unintended pregnancy and disparities between groups, and compared  this data to rates in 2001.

 They found that the percent of unintended pregnancies remained high, with a slight increase (from 48% to 49% of all pregnancies) from 2001 to 2006. The actual rate increased from 50 to 52 unintended pregnancies for every 1000 women aged 15-44. There was a significant decrease in the rate of unintended pregnancies in women 15-17 years old, but this group still had the highest rates (79%, down from 89%). While the fact that an increased percentage of pregnancies in such young women were intended is not necessarily a good thing, the overall pregnancy rate per 1000 decreased from 47 to 42 in this group. The rates of unintended pregnancy went down with age, but all other age groups had an increase in their rates from 2001-2006, the largest in women 18-24. To say this again: the rates of unintended pregnancy went up in each age group except 15-17, but that group still had the highest rate, with rates decreased in each older age group.

The most important finding was the disparity in the rate of unintended pregnancy by characteristics other than age: by race/ethnicity, by income, and by educational level. The unintended pregnancy rate for women with less than a HS diploma (80 per 1000) was more than 2.5 times that of college graduates (30); the rates for women who were HS grads and those with “some college” were in between. The rate for Black women (91) and Hispanic women (82) was also 2-3 times that of white non-Hispanic women (36). Income, perhaps, had the greatest disparity: the rate for women at <100% of poverty (132) was more than 5 times the rate for women >200% of poverty (24).

OK. This is a lot of data, and maybe it is hard to follow. But the main point is simple: these are staggering differences, and they are difference based upon the same social factors that Woolf and his colleagues address. The magnitude of these differences overwhelms all the other factors that affect this rate. The women whose resources make them least able to economically provide for unplanned children are most at risk of having them.

The percent of unintended pregnancies ending in abortion also decreased, from 47% to 43%, with the greatest decrease (from 47% to 41%) in women 20-24, but rather than being a positive, this decrease is much more likely to reflect the decreased availability of abortion services than a shift in attitudes toward abortion. That is, a larger number of children are being born as a result of unintended pregnancy to families that will have difficulty caring for them. In addition, these families are getting less and less aid from public sources because the same folks who are against abortion and the protection of the “unborn” are also against social services that will help the families of the born.

This study was also the basis for the excellernt column “Failing Forward” by Charles Blow in the NY Times on August 27, 2011.  He makes these points very strongly, commenting on the policies that restrict access to abortion while effectively punishing the children:
This is what we’re saying: actions have consequences. If you didn’t want a child, you shouldn’t have had sex. You must be punished by becoming a parent even if you know that you are not willing or able to be one. This is insane.”

As in all of Blow’s columns, he includes a telling graphic, here showing the “States of Child Hunger”, the rate and raw number of children in food-insecure households. There are over 17 million hungry children in the US, or 23.2% of all children. The highest rate is in DC, the lowest in North Dakota. After DC (32.3%), perhaps surprisingly, is Oregon (29.2%). However, after that, unsurprisingly, come the usual suspects , many of the states most commonly associated with poor social supports and frequently conservative Republican leadership: Arizona, Arkansas, Texas, Georgia, Mississippi, Nevada, South Carolina, Florida. Most of the New England states are clustered near the bottom (good) end of the list.

The whole thing is not good. Too many poor and hungry children, too little education, too little opportunity for too many women and their families. Too many people and families caught in the multiple challenges of poverty, poor education, and racial/ethnic minority status, all of which are independently associated with health disparities, and which are synergistic in their effect when found together. This is not a society to be proud of. This is a society that needs great change, and it is the change perhaps we’d hoped for with the election of President Obama.

Frequently, the comic strips (not even the overtly “political cartoons”) capture it best. Here is a link to a “Non Sequitur”, by Wiley Miller. Check out September 4, 2001, with the adventures of super “hero” “CongressMan”. Laugh. And then cry.

1 comment:

Machi said...

Two recent presentation address these issues:Why Should Physicians be Concerned About the Social Determinants of Health?


The Community as Patient: Mapping the Social Ecology of Access to Care in Bernalillo County

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