- Marjorie R. SableMarjorie R. SableSchool of Social Work, University of Missouri
- and Patricia J. KellyPatricia J. KellyUniversity of Missouri–Kansas City
Reproductive health includes family planning, prenatal care, and the broader scope of primary care. Because a woman's health status at conception is as important as prenatal care, genetic screening and 20th century medical technology, reproductive health includes “the preconceptual and interconceptual periods and the menopause, and finally, not only reproductive tract problems but the wide range of risk factors that influence a woman's health in general.” Quantitative indicators of reproductive outcomes are useful for summarizing progress in reproductive health. Important indicators are discussed and reveal significant racial disparities.
- Couples and Families
- Gender and Sexuality
- Health Care and Illness
- Policy and Advocacy
- Social Justice and Human Rights
Reproductive health includes family planning, prenatal care, and the broader scope of primary care. Because a woman's health status at conception is as important as prenatal care, genetic screening and 20th century medical technology, reproductive health includes “the preconceptual and interconceptual periods and the menopause, and finally, not only reproductive tract problems but the wide range of risk factors that influence a woman's health in general” (Kowal, 2004, p. 1). Quantitative indicators of reproductive outcomes are useful for summarizing progress in reproductive health. Important indicators are shown in Table 1 and reveal significant racial disparities.
Each year more than six million American women become pregnant. U.S. teen pregnancy rates and rates of new cases of sexually transmitted infections (STIs) rank among the highest among industrialized countries (Singh & Darroch 2000; Weinstock, Berman, & Cates 2004), as do infant mortality rate (IMR), low birth weight (LBW), and preterm birth (PTB) (U.S. Department of Health and Human Services [USDHHS], Health Resources and Services Administration, Maternal and Child Health Bureau, 2004a, 2004b). The teenage birth rate fell to 40.4 births per 1,000 women in 2005 from its 1991 high of 61.8, representing the lowest teen birth rate in its 65-year recording history (Hamilton, Martin, & Ventura 2007).
Unintended Pregnancy and Its Prevention
The USDHHS counts unintended pregnancy among major public health problems (Healthy People, 2010). Almost half of pregnancies in the United States are unintended, with 42% of them ending in abortion (Finer & Henshaw 2006). Women with unintended pregnancies are disproportionately young, low-income group, single, and non-white, primarily African American (Finer & Henshaw 2006). Unintended pregnancy has biological, psychological, economic, and social consequences (Brown & Eisenberg 1995). Compared with women with planned pregnancies, those with unintended pregnancies initiate prenatal care later (Kost, Landry, & Darroch 1998), have higher rates of behavioral risk factors during pregnancy (Berkowitz & Papiernik 1993; Brown & Eisenberg 1995; Poole & Hawkins 1999), and report higher rates of partner physical abuse (Gazmararian et al., 1995).
In 1970 the U.S. Congress enacted the Title X program as part of the 1970 Public Health Service Act. It is the sole federal program providing family planning and reproductive health care, funding around 4,600 clinics, preventing an estimated 1.3 million unintended pregnancies each year. Since 1995, an average of five million women each year obtained contraceptive services from these clinics. Nearly two-thirds of the clients have incomes below 100% of poverty level; 89% have incomes below 200% of poverty level. Congress has not increased Title X funding since 1981 (Office of Population Affairs [OPA], 2001).
Preconception care (Moos, 2002; Moos & Cefalo 1987) is a set of interventions to identify and modify biomedical, behavioral, and social risks to a women's health or pregnancy outcome. Preconception care counsels about unhealthy behaviors screens for and treats communicable diseases and endocrine conditions (that is, diabetes and hypothyroidism) and dispenses nutrients such as folic acid. Its goal is to increase awareness and address potential risks to women's health and pregnancy outcomes before a pregnancy is known (Johnson et al., 2006).
Pregnancy and Women's Health
Maternal mortality rate (MMR) had decreased markedly during the 19th century, but without much progress being made since mid-1980s. A Massachusetts study identified inadequate prenatal care as a prominent risk factor for MMR and declared that one-third to one-half of all maternal deaths were preventable (Sachs et al., 1992).
Profound racial disparities exist for all four indicators in Table 1. This remains true even when controlling for mothers' income and educational levels (Mustillo et al., 2004; Schoendorf, Hogue, Kleinman, & Rowley 1992). Other social risk factors for IMR include education and marital status. IMR decreases
white (non- hispanic)
black (non- hispanic)
Maternal Mortality Rate
Maternal deaths per 100,000 live births
Infant Mortality Rate
Infant deaths per 1,000 live births
Low Birth Rate
Percent of newborns weighing less than 2,500 g
Percent of births born less than 37 weeks gestation
From “Maternal mortality and related concepts,” by D. L. Hoyert, 2007, Vital Health and Statistics, 3(33). Hyattsville, MD: National Center for Health Statistics. Retrieved July 29, 2007, from http://0-www.cdc.gov.mill1.sjlibrary.org/nchs/data/series/sr_03/sr03_033.pdf; Infant mortality statistics from the 2003 period linked birth/infant death data file. National Vital Statistics Reports (Vol. 54, No. 16), by T. J. Mathews and M. F. MacDorman, 2006, Hyattsville, MD: National Center for Health Statistics. Retrieved July 27, 2007, from http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_16.pdf; and Births: Preliminary data for 2005. National Vital Statistics Reports (Vol. 55), by B. E. Hamilton, J. A. Martin, and S. J. Ventura, 2007, Hyattsville, MD: National Center for Health Statistics. Retrieved July 15, 2007, from http://www.cdc.gov/nchs/products/pubs/pubd/hestats/prelimbirths05/prelimbirths05.htm
with increasing maternal education and unmarried mothers are at higher risk for poor pregnancy outcomes (Mathews & MacDorman, 2006). Marital status is a marker for social, emotional, and financial support that independently impact these outcomes. Young maternal age, low education, and other negative social indicators are risk factors for LBW and IMR (Hamilton et al., 2007; Hillemeier, Weisman, Chase, & Dyer 2007; Mathews & MacDorman).
Early, comprehensive, and continuous prenatal care provides diagnosis and treatment for risk factors and advises pregnant women about behaviors to improve pregnancy outcomes (Brown, 1988; Mathews & MacDorman, 2006). Psychosocial assessment screens for risks, including tobacco, alcohol, and other substance use, depression, and domestic violence. Social worker screening and case management, available through “enhanced prenatal care” halves PTB or LBW risks (Wilkinson, Korenbrot, & Greene 1998).
The Institute of Medicine's seminal report on prenatal care (Brown, 1988) identified four barriers to prenatal care: (a) financial; (b) inadequate system capacity; (c) organization, practices, and atmosphere of prenatal services; and (d) cultural and personal. Despite the acknowledged importance of prenatal services, these barriers persist. In the 1980s Congress passed numerous laws, including the Omnibus Budget Reconciliation Act (OBRA) of 1987, expanding Medicaid eligibility to 133% of the federal poverty level for pregnant women and for 60 days postpartum (Margolis, Cole, & Kotch 2005). Its most important feature was making Medicaid receipt independent from receipt of Aid to Families with Dependent Children (AFDC) (now with Temporary Aid to Needy Families (TANF). In recent years Medicaid waivers also have provided women with well-woman care (Gold, 2003).
System issues relevant to inadequate prenatal care include problems securing Medicaid and other access barriers (that is, transportation problems), inconvenient hours or long waits in clinics, and communication problems with providers. Cultural and personal barriers compound system barriers. Fear of providers or medical procedures discourages some women, undocumented immigrants may fear of discovery, and women who abuse alcohol or illicit drugs may fear of prosecution. Lack of social support, stress, and depression also present barriers to prenatal care (Brown, 1988; Sable & Wilkinson 1999).
Factors Affecting Women's Reproductive Health
STIs, substance use, violence, and physical activity impact on women's overall health status.
Sexually Transmitted Infections
STIs increase women's morbidity, threaten fertility, and directly cause poor birth outcomes. Chlamydia has the highest infection rate of reportable STIs in the United States (Centers for disease control and prevention [CDC], 2006), is asymptomatic for many, and if untreated, can result in pelvic inflammatory disease and infertility (Gray-Swain & Peipert 2006). Gonorrhea symptoms and health effects are similar (CDC, n.d.-a; Zar, 2005). Gonorrhea, chlamydia, herpes simplex virus (HSV) infection, and bacterial vaginosis can impact birth outcomes (CDC, n.d.-b).
Infection with human immunodeficiency virus (HIV) can be transmitted to the baby during pregnancy, labor, delivery, or breastfeeding (perinatal transmission). In the United States, HIV testing and drug therapy has reduced the perinatal transmission rate to 2% or less (CDC, 2004). Only 142 cases of HIV or AIDS were diagnosed among babies exposed perinatally in the United States in 2005 (CDC, 2007). It is important to note that this low perinatal HIV transmission rate does not reflect women's reality in the developing world where HIV prevalence rates among pregnant women are between 25 and 45% (Reithinger, Megazzini, Durako, Harris, & Vermund 2007).
Almost 90% of pregnant women with active hepatitis B infection transmit it to their babies. Untreated infection results in chronic infection rates and resultant liver disease (March of Dimes, 2007). All U.S. babies are immunized at birth for hepatitis B infection; two additional doses are required during infancy to assure protection.
Substance Use, Tobacco, and Alcohol
Concurrent abuse of substances is frequent, complicating research on any substance's impact on birth outcome. Furthermore, many pregnant abusers are economically disadvantaged, a risk factor for unfavorable perinatal outcomes (Bolnick & Rayburn 2003).
Social workers can use the professional five intervention roles—teacher, broker, clinician, mediator, and advocate—in working with substance using women (Sun, 2004). Women-centered substance abuse programs address specific needs such as HIV or STI risk reduction, child care, reproductive health services, and parenting classes (Marsh, D'Aunno, & Smith 2000). Treatment strategies include empowering “recovering” women with reproductive health knowledge and decision-making skills (Jessup & Brindis 2005). Absence of woman-centered or pregnancy-specific services deters pregnant and parenting women from seeking treatment. Few treatment programs have special services for pregnant women (Brady et al., 2001).
More than 200 women have been prosecuted for fetal abuse for having abused substances during pregnancy (Marcellus, 2004). Treating substance use by pregnant women as criminal also deters women from seeking prenatal care and substance abuse treatment; social workers are obliged to serve as extensions of the legal system (Finkelstein, 1994; Paltrow, Cohen, & Carey 2000).
Approximately 20% of American women smoke, with higher rates found for those with less than a high school education; health consequences include infertility and conception delay (CDC, 2004). The IMR in 2003 was 71% higher for infants whose mothers smoked compared with those nonsmoking (11.3 per 1,000 vs. 6.6) (Mathews & MacDorman, 2006). Smoking during pregnancy is associated with LBW and intrauterine growth retardation (CDC, 2004). In 2002 and 2003, 18% of pregnant women reported smoking cigarettes. While many women are able to quit smoking during pregnancy, a significant proportion resume with the stress of parenting (Fang et al., 2004). Social workers are an important source of support for smoking cessation for all women. Research-based smoking cessation techniques are available (CDC, n.d.-c).
Excess alcohol consumption during pregnancy, especially during the first trimester, can result in a spectrum of congenital malformations and developmental disabilities known as fetal alcohol syndrome (FAS) (Baumann, Schild, Hume, & Sokol 2006; Foster & Marriott 2006). Fetal alcohol spectrum disorder (FASD) is a less-severe manifestation of FAS. FAS and FASD prevalence is underreported (Fox & Druschel 2003). Data from births during 1995–1997 indicate rates in some states ranging from 0.3 to 1.5 per 1,000 live-born infants; rates were highest for African American and American Indian or Alaska Native populations (CDC, 2002). The quantity of alcohol required to produce partial FAS or FAE has not been established. Current recommendations are to drink no more than one to two units of alcohol once or twice a week and avoid heavy drinking for pregnant women or for those planning pregnancy (Foster & Marriott 2006).
Violence against Women
Research since mid-1980s reports that intimate partner violence (IPV) is associated with increased mortality, injury and disability, poor general health, chronic pain, substance abuse, reproductive disorders, and poorer pregnancy outcomes (Plichta, 2004). Pregnant women are more vulnerable to violence; homicide leads the causes of death for pregnant and recently pregnant women (Shadigian & Bauer 2005).
Since the mid-1980s, then U.S. Surgeon General C. Everett Koop and others recommended routine screening for IPV during pregnancy (ACOG, 2006, 2007; USDHHS, 1986). However, screening rates and practices are far from optimal and enhanced violence prevention training for all practitioners working with women (Shadigian & Bauer 2005). Screening protocols must include an adequate referral network, and social workers are in a leadership position to advocate for services in the form of counseling, shelters, and legal assistance.
Nutrition and Exercise
Insufficient physical activity significantly contributes to women's morbidity and mortality. Ensuring sufficient physical activity in daily life is strongly related to social support and self-efficacy (Smith, Cheung, Bauman, Zehle, & McLean 2005). Less than half of pregnant women are physically active, increasing their risk for mood problems and pre-eclampsia (Poudevigne & O'Connor, 2006; Saftlas, Logsden-Sackett, Wang, Woolson, & Bracken 2004).
Obesity during pregnancy increases risk of maternal, fetal, and neonatal complications, diabetes, pre-eclampsia, caesarian section, and birth defects (Siega-Riz & Laraira 2006). Women entering pregnancy at higher weights are more likely to retain their increased gestational weight with subsequent pregnancies; women who retain their pregnancy weight increase risks of complications in future pregnancies, including gestational diabetes (Bainbridge, 2006). Clinicians discourage obese women from attempting weight loss during pregnancy (Yu, Teoh, & Robinson 2006).
Poverty and Racism
Women head more than half of poor families, and women and children constitute the fastest growing segments of poverty dwelling people (DeNavas-Walt, Proctor, & Lee 2006). Poverty is associated with inadequate health care and nutrition, excess stress and limited alternatives (Krieger, 2001). Problems persist for low-income women's accessing reproductive health services beyond the postpartum period. Some states are experimenting with Medicaid waivers for well-women's health that would provide primary health care services, including contraception and cancer screening (Gold, 2003).
Social determinants of health such as poverty and racism impact reproductive health outcomes (Krieger, 2001; Krieger, Rowley, Herman, Avery, & Phillips 1993; Institute of Medicine, 2003). Lu and Halfon (2003) posit that optimal reproductive outcomes result from health influences throughout life. Mustillo et al. (2004) found that women's self-reported experiences with racial discrimination were associated with PTB and LBW and concluded that this discrimination may contribute to the racial disparities in birth outcomes.
Politics threaten Title X program efforts and other measures to prevent unintended pregnancy. The Food and Drug Administration faced political pressure when reviewing over-the-counter approval for emergency contraception (Wood, Drazen & Greene 2005). Abstinence-only sex education is federally funded, despite insufficient evidence of its effectiveness (Brückner & Bearman, 2005; Jemmott, Jemmott, & Fong 1998). Politics threaten Title X program efforts and other measures to prevent unintended pregnancy. The Food and Drug Administration faced political pressure when reviewing over-the-counter approval for emergency contraception (Wood et al., 2005). In 1993, President Clinton suspended President Reagan's 1984 Global Gag Rule that had curtailed federal contributions for international family planning organizations providing abortion, counseling or reference for abortion, or advocating legal abortion (Population Action International, 2006); President George W. Bush reinstated the policy in 2001. A current international assistance program, The President's Emergency Plan for AIDS Relief, reserves one-third of all its funding for abstinence-only programs (Cohen, 2005).
Roles and Implications for Social Work
Social workers work in the reproductive health arena at the micro level by providing social support, counseling, education, and financial assistance to women and their families. Social workers must also help communities and society through social work practice at the macro level to support policies that emphasize prevention, increase access to the broad spectrum of reproductive health services, and lessen social determinants of health, such as poverty and racism. Social workers can advocate for policies and programs that reduce reproductive health risk factors, such as programs for smoking cessation, substance abuse prevention and treatment, violence prevention, nutrition and fitness, and poverty alleviation. We can advocate for access to reproductive health care for poor women beyond prenatal care and delivery by supporting Medicaid waivers for family planning and other reproductive health care in the preconceptional, postpartum, and interpartum periods. Finally, we must staunchly support efforts to reduce unintended pregnancy by supporting a woman's right to control her fertility, expanding access to these services for low-income women. As suggested by Miller, Piccinino, and Tsui (2005, p. 109), “nothing in the history of this country suggests that the family planning needs of the population are likely to be met without the strongest possible advocacy.”
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