Women's Health Policy in the United States: An American College of Physicians Position Paper

Hilary Daniel; Shari M. Erickson; Sue S. Bornstein

doi:10.7326/M17-3344

Position Papers |19 June 2018

Women's Health Policy in the United States: An American College of Physicians Position Paper Free

Hilary Daniel, BS; Shari M. Erickson, MPH; Sue S. Bornstein, MD; for the Health and Public Policy Committee of the American College of Physicians *

Article, Author, and Disclosure Information

Abstract

In this position paper, the American College of Physicians (ACP) examines the challenges women face in the U.S. health care system across their lifespans, including access to care; sex- and gender-specific health issues; variation in health outcomes compared with men; underrepresentation in research studies; and public policies that affect women, their families, and society. ACP puts forward several recommendations focused on policies that will improve the health outcomes of women and ensure a health care system that supports the needs of women and their families over the course of their lifespans.

Women face unique challenges over the course of their lifespans regarding their physical health, interactions with the health care system, and roles in society. They make up more than half of the U.S. population and are likely to live longer than men—women aged 85 years or older outnumber their male counterparts nearly 2 to 1 (1). Women use the health care system as patients, caregivers, and family representatives and can be particularly affected by costs, access issues, discriminatory policies, and lack of representation in biomedical and health outcomes research.

Both sex- and gender-specific issues affect women's health. Women may differ from men in disease expression, reaction to medications, or care management plans. They are more likely to be diagnosed or afflicted with certain diseases and conditions (including chronic or autoimmune diseases), and 38% of women have 1 or more chronic diseases, compared with 30% of men (2). Research suggests that risk factors related to chronic disease (such as diabetes, high cholesterol, and cardiovascular disease) are becoming more prevalent in women of reproductive age (3). Women also have unique mental health issues and depression, such as postpartum or perimenopausal depression. Women of diverse race/ethnicity, as well as women in the lesbian, gay, bisexual, transgender, questioning, intersex, or asexual (LGBTQIA) community, face greater health disparities than the general population, compounding specific issues in women's health.

Access to reproductive health care and health insurance has been and continues to be a barrier for women. Women in the United States are more likely to be covered by health insurance as a dependent (24% of women aged 19 to 64 years) than men, putting a woman at greater risk for losing coverage if she becomes widowed or divorced or if her spouse or partner loses his or her job (4). Uninsured women use fewer preventive services and are more likely to delay care because of cost (5). A woman's risk for being uninsured also varies by demographic, increasing to more than 20% for low-income women, those who lack a high school education, Hispanic/Latina women, and noncitizens (4). In addition, funding for family planning services and access to comprehensive reproductive health care are regularly disputed by state and federal legislatures, creating uncertainties and potential disparities around access to reproductive care.

As the health care system evolves, stakeholders must consider how to integrate women's health needs into policy discussion and capitalize on opportunities to improve the health of women, their families, and society. The American College of Physicians (ACP) makes 7 recommendations that aim to improve overall well-being throughout all stages of a woman's life and to address public policy issues that may result in barriers to health care access. The full position paper, including the expanded background and policy rationale, is in the Appendix.

Methods

This policy paper was drafted by ACP's Health and Public Policy Committee, which is charged with addressing issues that affect the health care of the U.S. public and the practice of internal medicine and its subspecialties. The authors reviewed available studies, reports, and surveys related to women's health from PubMed and Google Scholar between 1990 and 2017 and relevant news articles, policy documents, Web sites, and other sources. Recommendations were based on reviewed literature and input from ACP's Board of Governors, Board of Regents, Council of Early Career Physicians, Council of Resident/Fellow Members, Council of Student Members, and Council of Subspecialty Societies and nonmember experts in the field. The policy paper and related recommendations were reviewed and approved by the ACP Board of Regents on 16 April 2018. Financial support for the development of this position paper came exclusively from the ACP operating budget.

Positions and Recommendations

1. ACP believes that internists are well-suited to provide high-quality women's health care and that clinicians in all specialties and fields, including internal medicine, who care for women should receive appropriate training in health issues of particular relevance to the population of women seen in their practice setting. Training should emphasize both primary and comprehensive care of women, such as office gynecology, as well as the internist's role in team-based care for complex issues.

2. ACP believes that it is essential for women to have access to affordable, comprehensive, nondiscriminatory public or private health care coverage that includes evidence-based care over the course of their lifespans. Health insurers should not be allowed to charge women higher premiums or impose higher cost sharing on women because of their sex or gender.

3. ACP believes in respect for the principle of patient autonomy on matters affecting patients' individual health and reproductive decision-making rights, including about types of contraceptive methods they use and whether or not to continue a pregnancy as defined by existing constitutional law. Accordingly, ACP opposes government restrictions that would erode or abrogate a woman's right to continue or discontinue a pregnancy. Women should have sufficient access to evidence-based family planning and sexual health information and the full range of medically accepted forms of contraception.

4. ACP opposes legislation or regulations that limit access to comprehensive reproductive health care by putting medically unnecessary restrictions on health care professionals or facilities.

5. ACP supports the goal of universal access to family and medical leave policies that provide a minimum period of 6 weeks' paid leave and calls for legislative or regulatory action at the federal, state, or local level to advance this goal.

6. ACP supports increased availability of effective screening tools for physicians or health care professionals treating survivors of intimate partner or sexual violence. ACP supports increased patient education about intimate partner and sexual violence and the availability of resources for those affected by these abuses.

7. ACP supports efforts to improve the representation of women's health in clinical research and close knowledge gaps related to specific women's health issues.

Summary

Although the greater medical community recognizes that biological and social factors lead to differences in disease expression and treatment between men and women, further consideration of sex and gender is needed in the health care system's broader approach to women's health. Women face unique health challenges across their lifespans in addition to their roles in maintaining healthy families and meeting the health care needs of children and seriously ill family members. Ensuring access to nondiscriminatory health care coverage, ensuring access to a broad range of evidence-based services for reproductive health care, supporting public policies that positively affect women and their families, and closing knowledge gaps are essential to improving the overall health and well-being of women in the United States.

Appendix: Background and Rationale for Women's Health Policy in the United States: An American College of Physicians Position Paper

For the purpose of this paper, “women” and “female” refer to women of any cultural, racial, or ethnic background whose country of residence is the United States and who are primarily affected by U.S. regulations and laws. Many women's health issues are global, such as prevalence of certain types of cancer, reproductive and maternal health, behavioral and mental health, and violence against women. ACP acknowledges that certain cultural, political, and historical traditions affect the lives and health of women around the world. Female genital cutting, child marriage, and rates of sexually transmitted infections (STIs) and HIV/AIDS (6) continue to be significant concerns for women globally and require further dedicated analysis and policy considerations outside the scope of this paper.

Sex- and Gender-Specific Disease Issues for Women

Women and men differ in susceptibility, presentation, and expression of disease as a result of biological, social, and behavioral influences. Sex, the biological difference between men and women, and gender, the social constructs and behaviors associated with the sexes, can affect a woman's health (7). Women report a higher prevalence of disability than men (24.4% vs. 19.8%), and women account for 54 million of the 100 million Americans living with 1 or more chronic diseases (8, 9). Major issue areas for women include cardiovascular disease, diabetes, obesity, cancer, and mental or behavioral health. Compared with men, women are more likely to die within a year of a heart attack (10), more likely to delay going to the emergency department with cardiac symptoms, and less likely to receive aggressive prescription regimens (11). Women with diabetes are at higher risk for cardiovascular disease than men with diabetes (12) and are less likely to receive preventive care (13). Although women are less likely to be diagnosed with cancer, they are more likely to survive (14). Research shows that over the past 4 decades, the incidence rate of new cases of lung cancer has decreased 32% for men but increased 94% for women (15).

Women are 70% more likely than men to have depression (16). Psychological distress associated with balancing work and family can cause women to delay accessing health care compared with women who do not report this type of distress (17). Gender-based expectations also influence psychiatric care. More than half of women believe that depression is “a normal part of aging” (18). Social determinants can affect whether a woman has maternal depression, and mothers who live in poverty are 3 times more likely to have depression than those who do not (19). Women also face different challenges with substance use disorders from men: They respond differently to substances and can have more cravings and relapse after treatment or use drugs for less time before becoming addicted (20).

Health Issues for Special Populations

Racial/ethnic minorities and LGBTQIA women are more likely to encounter health care disparities than non-Hispanic, heterosexual white women. Women in racial/ethnic minorities face more challenges in accessing and receiving appropriate care than the general population. For example, American Indians and Alaska Natives have the lowest rates of mammography screenings, and rates among African American women, Asian women, and women with disabilities are also lower than in the general population (21, 22). Lesbians have higher rates of polycystic ovary syndrome than heterosexual women and may be at slightly higher risk for breast, ovarian, and endometrial cancer. However, they are less likely to get routine mammograms or cervical cancer screening. Women in the LGBTQIA population are also less likely to perceive themselves as at risk for STIs (23) and may be less likely to report instances of intimate partner violence (IPV) to authorities (24). Health disparities faced by LGBTQIA women can be compounded by race/ethnicity. Transgender women also face challenges in the health care system, including discriminatory coverage practices by insurers, difficulties regarding clinical competency on transgender health issues, and traditional gender norms that affect how society views and treats these women (25).

Reproductive Health Care

Reproductive Health and Family Planning

Women's reproductive health care includes several components related to the reproductive processes and systems of women across their lifespans. These may include but are not limited to miscarriage, ectopic pregnancy, pregnancy termination, sterilization, and contraceptive methods (26). However, significant attention is paid to reproductive health during the years in which women may become pregnant. Family planning is the entry point to the health care system and allows individuals and families to plan and space pregnancies. It also includes other services, such as breast and pelvic examinations, screening for breast and cervical cancer, efforts to test for and prevent STIs and HIV, and pregnancy diagnosis and counseling (27). Between 2006 and 2010, a total of 43 million women aged 15 to 44 years reported having received family planning or a related medical service in the past 12 months. Approximately half of the 18% of women who received such care at a clinic did so at a Title X–funded clinic. Use of Title X clinics is more common among women who live in a nonmetropolitan area or are black, Hispanic/Latina, below the poverty level, or uninsured (28).

Contraception

Contraceptive methods are used to prevent pregnancy and include short-acting hormonal birth control, barrier methods, long-acting reversible contraception (LARC), and emergency contraception. In addition to preventing pregnancy, some methods help relieve physical symptoms associated with the menstrual cycle. Approximately 14% of women who use short-acting hormonal birth control do so exclusively for noncontraceptive purposes (29). Adolescent girls and young women can be prescribed birth control pills for irregular menstrual periods, cramps, acne, endometriosis, polycystic ovary syndrome, or primary ovarian insufficiency (30). Although the safety, efficacy, and contraindications of various types of contraception have been established, access challenges remain. Some emergency contraception is available over the counter, but price, confusion about regulations for selling the drug, and inconsistency about which pharmacies stock it can make access difficult (31).

Pregnancy and Childbirth

For many women, pregnancy and childbirth can be a positive experience. Women's health outcomes after the birth of a child are affected by preconception health, health through pregnancy, and postpartum care. Social determinants, such as income, education, and employment, also correlate with reproductive health and can result in inequalities (32). In both 2015 and 2016, nearly 4 million births were registered in the United States (33). However, the United States has the highest maternal mortality rate among developed countries and is the only developed nation where that rate continues to increase. Since the Centers for Disease Control and Prevention began tracking pregnancy-related deaths (those caused by complications of pregnancy), the maternal mortality rate has steadily increased from 7.2 deaths per 100 000 live births in 1987 to a high of 17.8 deaths per 100 000 live births in 2009 and 2011. Large racial disparities also exist: Between 2011 and 2013, a total of 12.7 white women died per 100 000 live births, compared with 43.5 black women (34). One review of maternal deaths found that nearly 60% of pregnancy-related deaths were preventable (35). The 2 primary causes of death are cardiovascular disease and other medical noncardiovascular disease, indicating potential issues related to prenatal health or preventable disease.

Some women may determine that they wish not to continue their pregnancy, and in 2014 (the most recent year with available data), approximately 652 000 legal induced abortions were recorded in the United States, most (91.5%) of which occurred at fewer than 13 weeks' gestation (36). Carrying a child to delivery or choosing not to continue a pregnancy may have short- and long-term positive or negative effects on a woman. Legal abortion is shown to be safe for the woman (37), and a recent 5-year study of women's mental health and well-being after seeking abortion services showed that those who are denied wanted abortion services are at greater risk for negative mental health outcomes initially than those who want and receive an abortion and that those feelings generally improve over time (38). Each woman's experience in choosing not to continue a pregnancy is unique and influenced by various factors in her life, which may manifest in different ways across her lifespan.

IPV and Sexual Violence

IPV

Intimate partner violence is “a pattern of assaultive and coercive behaviors that may include inflicted physical injury, psychological abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation, and threats” (39). Perpetrators of IPV can be current or former spouses or partners or those who wish to be in an intimate relationship with a person. Approximately 20 persons per minute are abused by an intimate partner in the United States (40). Intimate partner violence can affect survivors' physical and mental health in the short and long term and is associated with no fewer than 40 negative physical, reproductive, psychological, social, or health behavior outcomes (41). Although both men and women can experience IPV, women are more likely to be abused. Between 1994 and 2010, 4 in 5 survivors of IPV were female (42).

Women are more likely to be killed by an intimate partner or someone they know than by a stranger, and between 67% and 80% of intimate partner homicides involve physical abuse of a woman before the murder regardless of which partner is killed (43). Of all female homicide victims, 64% are killed by someone they know, most frequently (45%) by a spouse, former spouse, boyfriend, or girlfriend (44). Conversely, 16% of male homicide victims in 2007 were killed by a family member or intimate partner (44). Firearms may also increase the probability of death in IPV incidents: Women are 5 times more likely to be killed by their abuser if he or she owns a firearm (45).

Gender-based violence also predicts suicidality in women and can be connected with substance use. In a survey of more than 3000 persons by the National Center on Domestic Violence, Trauma & Mental Health, 26% of participants reported using alcohol or drugs to self-medicate. These participants also reported that their partners or former partners used the participant's substance use to discourage them from seeking help or threatened to use the information to undermine their credibility with authorities (46).

Sexual Violence

Sexual violence refers to crimes that include sexual assault and rape. Women are much more likely to be survivors of sexual assault than men. The National Violence Against Women Survey found that 1 in 6 women (17%) and 1 in 33 men (3%) reported being survivors of attempted or completed rape during their lifetime (47). Sexual violence can have physical and psychological consequences. Victims of sexual violence are also more likely to engage in high-risk behaviors that increase the potential for future attacks (48).

Parental and Medical Leave Policies

The United States is the only developed nation and 1 of 2 countries out of 185 surveyed by the International Labour Organization that does not offer some degree of paid maternity leave; it is 1 of only 4 high-wealth countries without paid paternity or parental leave (49). As of March 2016, only 13% of workers in the private sector had access to paid family leave, which includes parental leave or leave taken to care for a seriously ill family member (50). In addition, the rate at which new mothers with access to maternity leave use that leave has remained stagnant. A recent analysis showed no significant trend upward or downward in women who took maternity leave between 1994 and 2015 (51). The analysis showed that 47.5% of women who took maternity leave in 2015 were compensated, an average increase of only 0.65% over nearly 2 decades.

As many as 75% of all caregivers are women, and female caregivers spend as much as 50% more time providing care than men (52). Women reported making 27% of decisions affecting their children, 20% affecting their spouse or partner, and 6% affecting adult relatives (53). Those who care for a close relative are at higher risk for poor health due to physical and emotional stress associated with the caregiver role. Stress associated with long-term caregiving can include depression and anxiety, a weakened immune system, obesity, higher risk for chronic diseases, and problems with memory (54). Seventeen percent of caregivers reported their health as “fair” or “poor,” compared with 10% of the general adult population (55). Caregiving caused a change in the work situation of 6 in 10 caregivers, including reducing work hours, taking unpaid leave, or receiving warnings about performance or attendance (55).

No federal laws require a standard level of paid parental or medical leave. The Family and Medical Leave Act (FMLA), signed into law in 1993, offers employees who meet certain requirements up to 12 weeks of unpaid, job-protected leave each year and requires employers to maintain the employee's health benefits during that time (56). Employees of all public agencies, public and private schools (elementary and secondary), and companies with 50 or more employees can use FMLA for the birth and care of a newborn child, adoption of a child, or foster care; to care for an immediate family member with a serious health condition; or if the employee cannot work because of a serious health condition. The FMLA defines “immediate family member” as a spouse, child, or parent but excludes grandparents and family members through marriage or domestic partnership (56).

California, New Jersey, Rhode Island, New York, Washington, and the District of Columbia have passed laws requiring employers to make paid leave available for the birth or adoption of a child, for a disability (which often includes pregnancy), or to care for an ailing family member with a serious medical condition. California, New Jersey, and New York are the only states that currently offer paid family leave to residents, and Washington and the District of Columbia have passed laws that will take effect at a later date (57). Programs in California, New Jersey, Rhode Island, and New York are structured to coordinate with existing temporary disability benefits to support a longer duration.

Recommendations and Positions

Internists are trained to diagnose and treat basic to complex chronic illnesses and are well-suited to provide care for adolescent and adult women. However, not all internal medicine physicians feel prepared to address some important issues in women's health. Enhanced or specialized training in such issues can improve the overall care of women across their lifespans, as well as improve access to routine services. More robust consideration in medical school, residency, and fellowship of the unique health needs of women will help physicians provide care to the largest number of women (including adolescent and aging women) and increase awareness of the most common causes of female mortality in their patient populations.

Primary care has been identified as an avenue to increase access to certain reproductive health services, such as LARC, in areas where access is restricted by government intervention or lack of women's health clinics or providers. However, barriers prevent these proposals from translating into policy changes. A survey of New York City physicians' views about providing LARC to adolescents identified both knowledge gaps and limited access to the device as reasons why the physicians rarely counseled their patients about LARC (58). These barriers should be addressed to encourage LARC uptake. Insurance reimbursement can be inadequate, and although the device should be covered under the contraception coverage mandate in the Patient Protection and Affordable Care Act (ACA), not all insurers comply (59). Promoting the safety of these methods and training in LARC insertion among primary care physicians and patients and addressing issues about same-day availability of LARC in primary care settings can enhance access and potentially increase use of this highly effective contraception.

The health needs of women throughout their lifespans require the specialized training of various health care professionals. In addition to preventive care and the treatment and management of disease, primary care physicians traditionally play a role in preconception and postpartum care. They can help women address obesity, blood sugar, diabetes, and cardiovascular issues that may lead to preeclampsia, all which may increase the risk for adverse health effects during pregnancy. Additional opportunities for training on acute care management of pregnant women and in the immediate postpartum period in the hospital setting should also be explored, particularly in light of high maternal mortality rates.

Women must have access to and a longitudinal relationship with a primary care physician who understands a woman's individual health needs at each stage of her life, as well as subspecialists who are able to care for the specific health-related issues women may face. Internists can treat various illnesses and conditions, conduct examinations, administer vaccines, and provide preventive care, but they may not be properly trained to care for women having high-risk pregnancies or provide the distinct perspective of pediatricians treating young women or geriatricians treating older women. Health care professionals, working with other members in a medical practice, support women's increased access to care and help create a partnership between a patient and members of her care team. A 2013 position paper (60) detailed the need to enable greater collaboration, communication, and cooperation to better serve patient needs and provide the best possible care for all patients.

Before the ACA was passed, one third of women who applied for a health plan independently were turned down, charged a higher premium, or excluded because of previous health problems (61). A report analyzing state-by-state coverage in the individual market before full implementation of all ACA provisions also showed that coverage for female-specific health care services, such as maternity care, was severely lacking (62).

The ACA contains many provisions that specifically support women's health and access to health care coverage. It requires plans to contain certain essential health benefits (including maternity care and preventive services) and to cover preventive care with no cost sharing (including well-woman visits, preconception care, and human papillomavirus testing). The ACA also ensures access to all contraceptive methods approved by the U.S. Food and Drug Administration with no cost sharing. Efforts to undercut the ACA's provisions, weaken or eliminate its essential health benefits, and allow employers and individuals to purchase plans that do not cover essential health benefits will negatively affect women and women's health care.

Additional policies are required to ensure that every American, including women, has health insurance coverage for the full range of evidence-based care he or she requires to remain healthy and obtain treatment when unhealthy. Such coverage should include prevention and wellness services, screening for conditions typically or exclusively found among women, family planning and reproductive care, contraception, preconception care, maternity care, postpartum care, care throughout menopause, mental and behavioral health care, substance use disorder treatment, and prevention and management of chronic diseases.

Access to health insurance coverage is important in supporting not only a woman's physical health but also her financial stability (63). Women pay more out of pocket than men overall because they use more health care. Therefore, access to affordable coverage that appropriately covers all aspects of women's health will spare women the choice between getting preventive or immediate health care services and paying for basic necessities like housing and food. Low-income, diverse, and younger women are more likely to be uninsured and be negatively affected by high out-of-pocket costs for health care. ACP also strongly opposes efforts to cap or cut Medicaid or convert it into a block grant program. Two thirds of adult Medicaid beneficiaries are women (64), and the program paid for nearly half of all U.S. births before the ACA was implemented (64). Inadequate or reduced funding forces programs to limit the number of eligible patients or the benefits they receive.

ACP believes that a woman has the right to make her own decisions, in consultation with her physician or health care professional, on matters affecting her individual health. Reproductive decision-making rights should be based on the ethical principle of respect for patient autonomy. Women should have access to the health care services they may need in their lifetimes, including reproductive health care and contraception. They should feel empowered to make decisions around pregnancy that are grounded in evidence-based information and reflect their own circumstances, which may result in a woman delivering and raising a child, choosing adoption, or choosing abortion. Limiting access to evidence-based medicine greatly affects a woman's ability to make her own health care choices. Reproductive care is a key component of women's health, and limiting access can have lasting repercussions on a woman's physical and mental health, economic well-being, and social mobility.

One of the most complex, controversial, and politicized issues in women's health care is access to comprehensive reproductive health services, specifically abortion. Such services may include but are not limited to management of miscarriage, ectopic pregnancy, pregnancy termination, sterilization, and contraception (26). The landmark decisions by the Supreme Court in Roe v. Wade and Planned Parenthood of Southeastern Pennsylvania v. Casey established the current legal frameworks that regulate a woman's right to abortion. Since 1973, Roe v. Wade has asserted a woman's right to privacy regarding medical decisions without interference by the government, including the decision whether or not to continue a pregnancy before fetal viability, but it did not determine abortion as an absolute right. Roe v. Wade established a framework in which decisions about abortion in the first trimester should be left to the medical judgment of a woman and her physician but in which states may have a greater interest in the health of the mother during the second and third trimesters and could impose stronger regulations (second trimester) or regulations and bans (third trimester) (65). The decision in Planned Parenthood of Eastern Pennsylvania v. Casey in 1992 established the undue burden standard, which allows states to regulate abortion procedures in the first trimester as long as they do not put a “substantial obstacle in the path of a woman seeking an abortion before the fetus attains viability,” superseding the language in the Roe v. Wade decision (66). Current law also states that exceptions must be made to preserve the life of the mother.

Notwithstanding the Supreme Court's rulings, abortion remains a subject of intense debate among the American public, federal and state lawmakers, and jurists. ACP asserts that a woman's right over health care decisions for matters affecting her individual health must include the right to decide whether to continue a pregnancy. However, it recognizes and respects that individuals, including physicians and patients, may have deeply held personal beliefs that inform their views on abortion or contraception rooted in how they perceive the ontological or moral status of a fetus. Ethical, public policy, and religious or spiritual arguments raise questions about the nature of what it means to be a person. For example, those who support constitutional personhood (the concept that from the moment of fertilization a zygote is considered a fetus and should possess the same legal status as any other human being, with some or all constitutional rights) would oppose any type of abortion and some types of contraception (67), whereas others may oppose the procedure after fetal viability. Although the debate is often viewed through the lens of ardent support or opposition, attitudes and opinions about if and when abortion is acceptable vary (68, 69). ACP supports the current legal framework that allows women to obtain abortions before fetal viability or in later stages of pregnancy to protect the health of the mother and opposes efforts that would further restrict a woman's constitutional right to privacy in medical decision making, as upheld by the Supreme Court.

Supporting access to family planning services and all forms of contraception is essential to reducing the rate of unintended pregnancy and demand for abortion services. ACP reaffirms its support for federal, state, and local family planning grants for educational and clinical services. It continues to support evidence-based family planning and sex education programs, which can help to disseminate information about contraceptive methods, the social and economic impact of unintended pregnancy, and prevention of STIs. Access to family planning clinics that provide essential health care services (such as STI and HIV testing) continues to be a major issue for women, particularly those who are disadvantaged and at higher risk for unintended pregnancy. Evidence shows that rather than seeking care elsewhere when access to family planning services is limited, some women forgo preventive care or their usual contraceptive methods. An analysis of the effect of women's health clinic closures in Wisconsin and Texas showed that an increase of 100 miles to the nearest clinic decreased the rate of breast examinations by 11%, mammograms by 18%, and Papanicolaou tests by 18% (70). Exclusion of Planned Parenthood affiliates from the Texas Women's Health Program coincided with an increased rate of childbirth by women on Medicaid, suggesting that the exclusion may have prevented women from accessing family planning services (71).

4. ACP opposes legislation or regulations that limit access to comprehensive reproductive health care by putting medically unnecessary restrictions on health care professionals or facilities.

As of February 2018, laws in 23 states can be considered to go beyond what is necessary to ensure patient safety and may subject physicians to criminal or civil penalties if they violate the laws, some of which include regulation of the offices or sites where abortion procedures are performed. The safety of abortion procedures is well-established (37). Sixteen states have licensing standards that require clinics or offices providing abortions to meet state licensing standards for ambulatory surgical centers. In an amicus brief filed in opposition to a Texas law with such a requirement, the American Medical Association and American College of Obstetricians and Gynecologists called the requirement “devoid of any medical or scientific purpose” (72).

These state-level attempts to restrict access to comprehensive reproductive health services, including abortion, impose medically unnecessary regulations that can interfere with the patient–physician relationship and make it difficult for patients to access health care professionals or assistance at facilities that counsel on or offer abortion services. ACP opposes regulation of reproductive health care services that is not focused on patient safety or based in accepted science. Public health policy about women's reproductive health and health care services should first and foremost be based in clinical research, with an emphasis on health promotion, prevention of unintended pregnancy, and access to reproductive health services.

ACP strongly reaffirms the position that “laws and regulations should not mandate the content of what physicians may or may not say to patients or mandate the provision or withholding of information or care that, in the physician's clinical judgment and based on clinical evidence and the norms of the profession, are not necessary or appropriate for a particular patient at the time of a patient encounter” (73). These laws may interfere with the relationship between physicians and patients or make access to reproductive health care services or abortion extremely difficult or impossible. Physicians may personally choose not to provide certain reproductive services or information about these services if it conflicts with their moral or personal standards. However, they still have a duty to inform patients about care options and alternatives or refer them for information (so that patient rights are not constrained) and provide information that is evidence-based and free of personal bias (74).

Paid leave policies can improve health outcomes for women and their families, on whom a new child can have significant physical and emotional effects. The birthing process is physically taxing, and women continue to have physical and hormonal changes for weeks or months afterward. An analysis of mothers at various periods after childbirth showed a relationship between leave duration and decreases in depressive symptoms until 6 months postpartum (75). Paid maternity leave is associated with increased likelihood of breastfeeding initiation and continuation at 6 months compared with no paid leave (76). Breastfeeding can have positive health outcomes for both child and mother, including providing some protection from common childhood infections in a baby's first year of life, helping a woman recover after the birth, and reducing risk for breast or ovarian cancer (77, 78). In addition, paid parental leave for men can reduce stress on families and encourage father–child bonding (79).

Guaranteeing at least 6 weeks' paid leave for both men and women allows employees already experiencing major life changes to focus on their physical health and the health of their families without added stress. Such policies should include minimum standards for paid leave and dedicated funding to help employers provide such leave. Analyses of states with paid leave policies show an overall positive effect. A study of California's policy showed that access to the benefits increased new mothers' leave by 3 weeks, positively affected children and mothers, and did not cause problems for most employers (around 90% reported positive effects) (80). Paid leave makes economic sense for employers as well as employees. Employers who offer paid leave are more likely to retain employees and more attractive to job seekers. In New Jersey, approximately 76% of workers view the law favorably, and businesses claim they have adjusted well (81).

Despite the availability of FMLA to about 60% of the American workforce, some caregivers still cannot afford to take unpaid time off, and existing public policies do not sufficiently support women or their families in a way that does not risk economic stability or position in the workforce. Paid leave policies should ensure increased flexibility for caregivers to care for family members, including children (biological or adopted), spouses, partners, parents, parents-in-law, or grandparents. Policymakers should also consider revising FMLA to reflect the current workforce and more flexible family structures that may include grandparents or in-laws. Reforms should be structured to minimize disruption for employers while providing the same standard of job protection for employees and consideration of the financial hardships and stress experienced by caregivers and their families.

ACP recognizes that universal access to at least 6 weeks of paid family leave may bring unique challenges for smaller employers, including private physician practices and nonprofit organizations. Therefore, legislation to expand paid leave should consider potential burdens on employers while upholding the intent of the programs through dedicated funding, necessary accommodation, and assistance to help small businesses transition to a minimum of 6 weeks of paid leave.

Additional studies are needed to determine the optimal amount of paid time off to maximize the associated health benefits for employees; discourage the “motherhood penalty,” in which women face bias and wage gaps resulting from their potential or actual taking of leave; examine whether paid leave policies should be integrated into or administered by unemployment insurance programs; balance the economic benefit for employers against costs; determine an appropriate level of imbursement during leave; and research additional mechanisms that may help finance paid leave, such as payroll taxes or reforms of existing programs (for example, Social Security) (82).

The physical, mental, and behavioral health effects of IPV are well-documented, including increased morbidity and mortality. Unfortunately, many victims of IPV or sexual violence go unrecognized. Primary care practices provide a confidential environment and private space that is particularly important in light of the low reporting rate of IPV against women. The U.S. Preventive Services Task Force rates screening for IPV in pregnant women but is currently reviewing that recommendation as well as screening recommendations for elder abuse and abuse of vulnerable adults (83). The rate of screening for IPV in primary care offices ranges from 1.5% to 12% (84).

Many physician barriers may make identifying or screening for IPV challenging. These include feelings that discussing the topic is “too close to home,” personal discomfort with the topic, a belief that asking about IPV is too personal, lack of education and training, lack of time to screen and respond, a belief that physicians should not address IPV, and fear of repercussions from mandatory reporting laws in their state. Institutional barriers also prevent IPV from being recognized and addressed, including lack of training, legal issues involving insurance discrimination, mandatory reporting requirements, and lack of diagnostic or procedural codes for violence. Finally, research on IPV is limited by concerns about ethics, safety, and privacy; lack of uniform or standard definitions for IPV; and an overall lack of funding for research on violence (85).

An emerging area of interest is how to develop effective screening measures for potential perpetrators of violence, including IPV and sexual violence. There is little empirical evidence on methodology, best practices, or effectiveness of this type of intervention. Despite this, several measurement tools exist, including the Abuse Within Intimate Relationships Scale, Abusive Behavior Inventory–Partner Form, Physical Abuse of Partner Scale, Revised Conflict Tactics Scale, and Non-Physical Abuse of Partner Scale. In an effort to address prevention of IPV and sexual violence, additional research should investigate whether these methods are effective in preventing or reducing incidents of IPV or sexual violence.

Sexual violence and IPV are very sensitive subjects, and not all victims will feel comfortable raising these issues, even with trusted health care professionals in a private setting. Creating an environment in which awareness of the topic is increased can help the patient feel more comfortable discussing any issue they may have had. For patients who are not ready to disclose IPV to a clinician, primary care practices can improve awareness of and access to IPV resources by hanging posters and providing pamphlets, palm cards, and contact lists for national and local resources in the office or on their Web site. These resources should also include information for victims of human trafficking or sexual exploitation.

7. ACP supports efforts to improve the representation of women's health in clinical research and close knowledge gaps related to specific women's health issues.

Women's health research and its applications serve a broader societal purpose. Women make up more than half of the U.S. population, but these research gaps continue to contribute to disparities in health care treatment of women. Several troubling trends are affecting the overall survival of U.S. women, such as the decreasing life expectancy of lower-income white women (86), increasing rate of maternal mortality, prevalence of binge drinking among older women (87), increasing rate of STIs in older women, and increasing suicide rate among women (88). All women in the United States must have access to the best available health care—starting with a comprehensive understanding of the science behind women's health and health needs—as well as the resources necessary to effectively address women's health issues and take steps to reduce negative outcomes.

In 1985, a workgroup of the U.S. Public Health Service reported that the exclusion of women in research negatively affected the quality of knowledge related to women's health issues (89). Considerable efforts have been made since then through policy changes, regulations, and the establishment of offices of women's health in federal agencies to better support scientific research on women's health. However, clinical trial investigators do not necessarily distinguish sex or gender differences in their data. Large research gaps therefore remain in understanding how women react to or are affected by certain medications. Despite advances in certain areas since 1985, progress is lacking in unintended pregnancy, maternal morbidity and mortality, autoimmune diseases, alcohol and drug addiction, lung cancer, gynecologic cancer other than cervical cancer, nonmalignant gynecologic disorders, and Alzheimer disease (90). In addition, certain groups (particularly disadvantaged women) have not seen improved health outcomes in the areas where major progress has been made, namely breast cancer, cardiovascular disease, and cervical cancer.

Although efforts to increase female participation in clinical studies have improved representation of women in research generally, more attention should be focused on how sex and gender affect disease, disease treatment, and social factors (91) as well as disease expression, health outcomes, and treatment protocols. Gaps in women's health research not only are detrimental to the health of women but also prevent policymakers from properly addressing sex or gender in outcomes measures or understanding the return on federal investments into biomedical research. In a review of 2 decades of medical literature on the comparative effectiveness of treatments for coronary artery disease in women, 65% of articles were excluded because they did not report sex-specific data and only 17% of articles reported sex-specific outcomes (92).

Research must also reflect the broader demographic makeup of the United States, and efforts should include increased participation of women of different races or ethnicities and LGBTQIA women in research studies. Demographic changes in the overall population show that those who identify as racial/ethnic minorities make up a larger part of the population than previously, and research must adequately represent them. Despite progress in female representation in studies, some racial minorities—especially African American or black women—remain underrepresented in most drug development programs (93). This may prevent generalizability of clinical trial results in this population.

Representation of LGBTQIA persons should also be addressed. Lesbians and gay men are sometimes excluded from clinical trials on the basis of their sexual orientation, particularly in studies of sexual health or function, without scientific reasoning (94). Lesbian, bisexual, or transgender women may also be hesitant to participate in research studies because of reluctance to share their sexual orientation or gender identity status with researchers due to concerns about privacy; being judged; potential lack of cultural competence by researchers; or avoiding stigma, harassment, or discrimination (95). Although excluding certain persons from clinical research who are not in the target population of the study is not uncommon, researchers should ensure that this is not done in a discriminatory manner.

Conclusion

Health care is important to women's personal, social, and economic well-being. Policymakers must take into account the health needs of women over their lifespans and take action to strengthen the health care system and societal structures to support women and their families. Ensuring access to care that accounts for the unique health needs of women, ensuring affordable and nondiscriminatory health care coverage, improving awareness of issues particularly affecting women, and ensuring that women's health care decisions are respected are all steps on the path to improving women's health in the United States. Addressing these issues will advance the goal of achieving health equity among all citizens and will improve health care outcomes for women of future generations.

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Video News Release - Women's Health Policy (4:01)

ACP President Ana María López, MD, FACP explains why health care is a crucial issue for women and their families and what ACP recommends to improve current U.S. policies.

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3 Comments

Paul M. Shaniuk, MD

Louis Stokes Cleveland VA Medical Center

June 20, 2018

Women’s Health Policy Position Statements on Abortion Do Not Reflect the Views of All Members of the American College of Physicians

Dear Editorial Staff,

The Position Paper “Women’s Health Policy in the United States,” highlights many important issues in women’s health, but positions #3 and #4, regarding abortion and the standards of abortion centers, mar this paper greatly. Policies should promote the best interests of all patients, and in the case of pregnancy, two patients exist. Both science and the law affirm the basic humanity of a fetus. Any student of basic embryology understands the scientific argument, but legal arguments exist as well. This is evidenced by existing fetal homicide laws in every state(1). The contentious debate centers on the fetus’ rights, not its humanity, and whether these rights depend on reaching a specific stage of development or based on a pregnancy’s desirability. Reasonable physicians stand on both sides of this debate, as noted in the policy statement. Unfortunately, after several tactful and balanced paragraphs, the final statement ignores all such nuance. Disappointingly, the College took a firm stand against the rights of the unborn child.

Regardless of one’s side on this polarizing issue, all physicians seek the goal of increasing patient safety. Thus, position #4 should not have been controversial. Yet, in a paper promoting Women’s Health, the Editorial Board decided to recommend against legislation requiring abortion facilities to improve safety standards. It was shocking to read the cited Amicus Brief opposing HB2 in Texas, and to learn that “routine sterile precautions,” such as masks and gowns, were considered unnecessary(2). Why argue against full sterilization of instruments or increased infection control measures? Why not ensure that clinics apply the financial capital necessary to reduce the risk of complications or to expedite the care of patients who may suffer them? As with any medical procedure, abortion is not always universally and uniformly safe. During my residency, I witnessed the tragic case of a young woman who died of sepsis following an elective abortion. Americans United for Life recently published a report, titled UNSAFE, identifying dozens of abortion clinics in more than 30 states cited for blatant health code violations(3). Whole Women’s Health, the very clinic named in the quoted Amicus Brief, has multiple citations(4). The College should not stand against policies promoting patient safety, regardless of ideological viewpoints.

These positions should be revised to acknowledge that many within this College are committed to care for both unborn persons and vulnerable mothers. Their viewpoints should not be discounted.

1. National Conference of State Legislatures (2018, May 1st) State Laws on Fetal Homicide and Penalty-Enhancement Against Pregnant Women. Retrieved from http://www.ncsl.org
2. Brief of Amici Curiae American College of Obstetricians and Gynecologists and the American Medical Association in support of plaintiffs-appellees-cross-appellants and in support of affirmance. No. 14-50928. 2014. Accessed at www.reproductiverights.org/sites/crr.civicactions.net/files/documents/2014-12-01%20-XX-%20Amicus%20Brief--ACOG%20and%20AMA.PDF on 2 June 2018.
3. Americans United for Life UNSAFE Report - http://www.lifeissues.org/wp-content/uploads/2017/01/UNSAFEreport.pdf Retrieved from http://www.unsafereport.org
4. Texas Department of State Health Services, Statement of Deficiencies and Plan for Correction, Whole Women’s Health - Beaumont, dated October 2, 2013, available at http://ftpcontent. worldnow.com/kbmt/CLINIC-REPORT.PDF

David Carl Houghton, MD, FACP, FAAP

Intermountain Healthcare

June 28, 2018

Injection of politics into ACP position papers is inappropriate

I agree wholeheartedly with Dr Shaniuk's comments about the regrettable decision by the ACP to use its scientific reputation to sway a political debate. Embryological science is incontrovertible about the fact that a fetus is an independent human organism. "Continuing a pregnancy" is a term that arbitrarily places a mother's health concerns above the basic acknowledgement of this scientific fact.

There is no scientific difference between a mother who chooses to stop feeding her newborn, and a mother who chooses to "discontinue a pregnancy". There are valid ethical dilemmas involved to be sure, but these are not at all addressed in the ACP position paper, and really cannot be, as these are outside the realm of medical science.

Saying that government regulation limiting access to abortion interferes with women's medical autonomy is akin to saying that laws prohibiting euthanasia interfere with medical autonomy. Are laws against euthanasia "medically unnecessary"? And since when is the medical/ethical appropriateness of ending life "defined by existing constitutional law"? Did the laws of 1930s Germany make the crimes of Nazi-employed physicians justifiable?

The debunking of dubious claims about the maternal risks of abortion is woefully insufficient to address the monumental ethical issues involved. ACP leadership should refrain from using the ACP's reputation to advance their preferred political causes. We cannot afford the public or policymakers questioning the basis for ACP recommendations on critical health issues.

Hilary Daniel, BS Shari M. Erickson, MPH Sue S. Bornstein, MD

ACP

October 11, 2018

Author's Response

The authors appreciate the opportunity to respond to the comments made by Drs. Shaniuk and Houghton. The topic of reproductive health care services is a complex, personal, and often polarizing issue and ACP respects the diverse viewpoints of its members. However, we must respectfully disagree that ACP is using its reputation to influence a political debate or that the scientific reasoning in the paper is misguided. In this paper, ACP advocates for a women’s right to make her own health care decisions in consultation with her physicians and within her constitutional right to privacy . Women should have access to evidence-based health care services and medically accurate information, including about reproductive health care services, in order to make informed health care decisions throughout their lives.
ACP and all clinicians share the goal of improving patient safety. The authors feel strongly that position 4 does not oppose efforts to improve patient safety but rather opposes laws or regulations with the primary intent to limit access to or the practice of abortion through medically unnecessary measures. In his comments regarding what the American Medical Association and the American College of Obstetricians and Gynecologists deemed medically unnecessary in an amicus brief opposing to HB2, Dr. Shaniuk omits the organizations’ reasoning behind considering “routine sterile precautions” as unnecessary. The organizations opposed the measure because under standard medical practice, “clinicians performing abortions access the uterus through the vagina, which is known as a “clean-contaminated field” and is not naturally a sterile space.”
Laws such as HB2 would continue to put access to safe abortion services at risk and increase the risk of potential adverse health consequences for women. Available evidence on the safety and quality of abortion care in the U.S. shows that legal abortion is safe and that serious complications occur less frequently than during pregnancy. However, the quality of these services depends on where a woman lives. In areas that have implemented regulations that create barriers to safe, effective, timely, and patient-centered abortion care, the quality of care provided by clinicians is affected .
Sincerely,
Hilary Daniel, BS
Shari M. Erickson, MPH
Sue S. Bornstein, MD
Roe v. Wade, 410 U.S. 113 (1973)
73. Brief for Whole Woman’s Health et al. as Amici Curiae in support of Plaintiffs-Appellees-Cross-Appellants v David Lakey et al. Accessed at https://www.reproductiverights.org/sites/crr.civicactions.net/files/documents/2014-12-01%20-XX-%20Amicus%20Brief--ACOG%20and%20AMA.PDF
National Academies of Sciences, Engineering, and Medicine. 2018. The safety and quality of abortion care in the United States. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24950.

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2018 American College of Physicians

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Position Papers |19 June 2018

Women's Health Policy in the United States: An American College of Physicians Position Paper Free

Abstract

Methods

Positions and Recommendations

Summary

Appendix: Background and Rationale for Women's Health Policy in the United States: An American College of Physicians Position Paper

Sex- and Gender-Specific Disease Issues for Women

Health Issues for Special Populations

Reproductive Health Care

Reproductive Health and Family Planning

Contraception

Pregnancy and Childbirth

IPV and Sexual Violence

IPV

Sexual Violence

Parental and Medical Leave Policies

Recommendations and Positions

Conclusion

References

Clinical Slide Sets

Video News Release - Women's Health Policy (4:01)

This feature is available only to Registered Users

3 Comments

See Also

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Related Topics

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Content

Information For

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Awards and Cover

Other Resources

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Position Papers |19 June 2018

Women's Health Policy in the United States: An American College of Physicians Position Paper Free

Abstract

Methods

Positions and Recommendations

Summary

Appendix: Background and Rationale for Women's Health Policy in the United States: An American College of Physicians Position Paper

Sex- and Gender-Specific Disease Issues for Women

Health Issues for Special Populations

Reproductive Health Care

Reproductive Health and Family Planning

Contraception

Pregnancy and Childbirth

IPV and Sexual Violence

IPV

Sexual Violence

Parental and Medical Leave Policies

Recommendations and Positions

Conclusion

References

Clinical Slide Sets

Video News Release - Women's Health Policy (4:01)

This feature is available only to Registered Users

3 Comments

See Also

Related Articles

Journal Club

Related Point of Care

Related Topics

PubMed Articles

Content

Information For

Services

Awards and Cover

Other Resources

Follow Annals On

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