Women’s public health policy in the 21st century

Women’s public health policy in the 21st century

FEATURE WOMEN’S PUBLIC HEALTH POLICY IN THE 21ST CENTURY Julie Mottl-Santiago, CNM, MPH ABSTRACT Midwives share a historic commitment with maternal...

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FEATURE

WOMEN’S PUBLIC HEALTH POLICY IN THE 21ST CENTURY Julie Mottl-Santiago,

CNM, MPH

ABSTRACT Midwives share a historic commitment with maternal and child public health (MCH) agencies to protect and improve perinatal health among vulnerable populations. Both professions are now beginning to broaden their responsibilities to include the comprehensive health needs of women. Because midwifery’s unique woman-centered primary care practices reflect the goals and aims of the developing MCH women’s health agenda, continued partnerships between midwives and the maternal and child public health community are imperative to promote the health of women and their families. To facilitate such collaboration, this article presents an overview of women’s public health policy and articulates the unique contributions midwives can and do make to women’s health care and public health policy. J Midwifery Womens Health 2002;47:228 –238 © 2002 by the American College of Nurse-Midwives. INTRODUCTION

Midwives have historically been committed to ensuring the health of the nation’s most vulnerable women and infants (1,2), a goal shared by federal and state maternal and child public health (MCH) agencies (3,4). Although perinatal health has traditionally been the primary focus of midwifery and MCH programs, today both disciplines are beginning to address comprehensive health care needs for women beyond those related to reproductive health. While many certified nurse-midwives (CNMs) and certified midwives (CMs)* are broadening their scope of practice to include primary health care for women through the postmenopausal years (5,6), MCH agencies are exploring their role in ensuring integrated and comprehensive health services that address the needs of the whole woman. Collaboration between midwifery and maternal and child public health initiatives can promote the women’s health agendas of both professions. The purpose of this article is to present an update on the status of women’s public health policy at the state and national levels and to promote understanding of the various roles women’s health care providers may assume in collaborations with public health agencies.

Address correspondence to Julie Mottl-Santiago, 138 1/2 Spring Street, Cambridge, MA 02141. * CNMs/CMs and midwives used herein refers to midwives who are certified by the American College of Nurse-Midwives (ACNM) or the ACNM Certification Council, Inc., and midwifery refers to the profession as practiced in accordance with the standards promulgated by the ACNM.

228 © 2002 by the American College of Nurse-Midwives Issued by Elsevier Science Inc.

HISTORIC OVERVIEW OF WOMEN’S HEALTH CARE POLICY IN THE UNITED STATES

Carol Weisman’s groundbreaking work (7,8) describes how women’s health care in the United States has traditionally focused on reproductive function, rather than comprehensive health. This focus can be traced to the mid-19th century beliefs that women’s reproductive organs controlled physical and mental well-being and that maternity was a woman’s primary purpose (7,8). The first federal maternal and child public health agencies were established in this social context. The Children’s Bureau, established in 1912, and the Sheppard-Towner Maternity and Infancy Act of 1921 created federally subsidized maternal and infant health programs that funded maternity education, prenatal care and children’s health clinics (7,9,10). The birth control movement also began during this period of time and drew attention to the need for legalized contraception and to women’s rights to control their reproductive lives. Despite tension between the birth control movement’s reproductive rights agenda and MCH’s child welfare agenda, the influence of both groups have helped to define women’s health as reproductive health (7). Public policy reinforcing this definition continued after the Sheppard-Towner Act with the enactment of Title V of the 1935 Social Security Act, Title X of the Public Health Service Act in 1970, the Special Supplemental Food Program for Women, Infants, and Children (WIC) in 1972, and Medicaid expansions for pregnant women in the 1980s (7,10,11). Title V and Title X continue to be the primary source of federal funding for women’s health programs (see Table 1). The establishment of obstetrics and gynecology as a medical specialty in the early 1930s and its growing prominence in the health care of women also has reinforced the perception that women’s health care is essentially reproductive health care (7). The Women’s Health Movement of the 1960s and 1970s challenged these perceptions of women’s health. Maternity was no longer perceived as the central focus of women’s lives, and male-dominated medical control over access to reproductive health was rejected. The impact of the movement on women’s health care was significant and included legalized abortion, the development of alternative forms of health care delivery, such as feminist health centers, and a large rise in the number of female

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TABLE 1

Major Federal Funding Sources for Women’s Health Services

Date enacted Goals Population served Funding mechanism

Budget Administrators Examples of funding uses

Title V of the 1935 Social Security Act*

Title X of the Public Health Service Act†

1935 To promote the health of women and children Pregnant women, children and youth, children with special health care needs 1. 83% federal block grants to states requiring matched state funding 2. 15% Special Projects of Regional and National Significance (eg, for training, education, research) 3. 2% Community Integrated Service Systems (eg, home visiting programs) $705 million (FY2000) Maternal and Child Health Bureau, DHHS 1. Infrastructure building: eg, needs assessment, evaluation, policy development, information systems 2. Population based services: eg, newborn screening, immunizations, outreach/public education 3. Enabling services: eg, family support services, case management, transportation 4. Direct health services

1970 To provide direct family planning services Poor and underserved women Federal money granted to family planning clinics through state MCH agencies and other grantees

Over $200 million (FY1999) Office of Family Planning, DHHS Subsidizes contraceptive delivery primarily for local family planning clinics and Planned Parenthood affiliates

* From: American College of Nurse-Midwives. Nurse-midwifery and maternal and child health in the United States: an educational module. Washington (DC): American College of Nurse-Midwifes, 2001 (4). † From: Gold, RB. Issues in Brief. Title X—Three decades of accomplishment. Reprinted from The Guttmacher Report on Public Policy, February 2001 (11).

physicians (7). In addition, rejection of medicalized childbirth and a growing interest in the empowerment of women during childbirth led to a renaissance of consumer demand for midwifery, home birth, unmedicated hospital-based birthing options, and woman-friendly hospital childbirth policies (12). The Women’s Health Movement also promoted the development of grass-roots women’s health advocacy groups. The Boston Women’s Health Book Collective and the National Women’s Health Network, established in the early and mid-1970s, continue today to advocate for woman-friendly government policies and to educate the public on a broad range of women’s health issues (13). The diversity of voices in women’s health care activism also has grown increasingly audible as women of color, lesbians, older women, rural women, and women with disabilities articulate their unique health care needs through local and national advocacy groups. The establishment of organizations such as the National Black Women’s Health Project, the National Latina Julie Mottl-Santiago completed her midwifery education, MPH, and the Maternal and Child Health Leadership Training Program at the Boston University School of Public Health in September 2001 and has recently joined the midwifery practices of Urban Midwife Associates and Boston Medical Center in Boston. She has a decade of experience working with international and domestic community-based women’s health programs.

Health Organization, the Native American Women’s Health Education Resource Center, and the National Asian Women’s Health Organization reflects the diversity of women’s health care needs and the importance of addressing health priorities and beliefs that may differ from those of the dominant culture (13,14) In the 1990s, women’s health activists worked to establish a broader view of women’s health in policy, research, and health care delivery (7). In particular, the political influence of an aging baby-boom generation has contributed to several important policy initiatives that address health care needs over a woman’s full lifespan, including the Breast and Cervical Cancer Mortality Prevention Act of 1990 and the National Institute of Health’s (NIH) Women’s Health Initiative research study on the health of midlife and older women. This large national study provides one response to criticism that clinical research has systematically discriminated against women through exclusion from clinical trials, application of research findings among the male population to women’s health care practices, and underfunding research on diseases that disproportionately affect women (12). Since 1990, federal agencies have also begun to organize women’s health offices to address comprehensive women’s health concerns. They include the NIH Office of Research on Women’s Health and the Centers

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health, as well as conferences addressing the development of effective perinatal care systems (15).

TABLE 2

Maternal and Child Health Bureau’s ● “A lifespan and holistic, multi-role approach to women’s health, with the implication that overall health includes but is not limited to pregnancy and reproductive health” ● “Pregnancy and prenatal care provide important windows of opportunity to build upon the foundation of knowledge and practice of positive health behaviors for women and their families. However, systems of care for women must be such that they effectively reach and engage in the care of women who will not become pregnant and/or do not access prenatal care.” ● “Affordable and accessible high quality health care must be available for women.” ● “Preventive, supportive health care addresses each individual’s physical, emotional, cognitive, spiritual, psychological and social needs.” ● “The efficiency and effectiveness of screening and intervention activities can be delivered in and optimized by the collaboration of both traditional health care settings and non-traditional settings.” ● “Consumer-oriented, family-centered, age- and culturallyappropriate health care must be linked to community services in a defined system of care.” * Adapted from: Health Resources and Services Administration, Maternal and Child Health Bureau, Division of Perinatal Systems and Women’s Health. DPSWH - five year women’s health plan, FY 2001–2006, full document. Washington (DC): 2001. (15).

for Disease Control and Prevention (CDC) Office on Women’s Health (7,12). The Health Resources and Services Administration’s (HRSA) Office of Women’s Health was created in 1995 to serve as coordinator of HRSA categorical women’s health programs and was reorganized into the Maternal and Child Health Bureau (MCHB) in 2000 (15). The Department of Health and Human Services’ (DHHS) has also recently established the National Centers of Excellence in Women’s Health to provide innovative comprehensive models of women’s health care (16). The recent reorganization of the HRSA Office of Women’s Health into MCHB provides a living example of how institutional commitment to women’s health care evolves and how women’s health care providers can advocate for women by participating in the development of new agendas. For example, since acquiring the women’s health office, the MCHB has created initiatives such as their Five-Year Women’s Health Plan (15). Although still in its initial stages, the plan may generate programs with larger funding bases as the role of comprehensive women’s health in maternal and child public health activities gains acceptance. This plan’s guiding principles and values share much with the woman-centered philosophy of midwives (see Table 2). Examples of opportunities for midwives to contribute to this women’s health agenda include meetings on health promotion/ disease prevention provider guidelines for women’s

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REDEFINING WOMEN’S HEALTH

As public awareness of women’s health care needs grows, the importance of a woman-centered definition of health becomes apparent. Traditionally, women’s health has been narrowly defined within a biomedical model that emphasizes disease processes and implies a male norm. This perspective ignores the unique social, political, and economic experiences that impact the health and well-being of women (7,17,18). Women’s health proponents today are advocating for a woman-centered, biopsychosocial model that is characterized by three key points: 1) health is a state of physical, mental, and social well-being, not merely the absence of disease; 2) women’s health is viewed from a life span and multirole perspective and includes, but is not limited to, reproductive health; and 3) women’s health is affected by social, cultural, and psychological factors, as well as by biology (7,17,18). PUBLIC HEALTH AGENCIES AND WOMEN: FROM REPRODUCTIVE TO COMPREHENSIVE HEALTH CARE

Why Should Maternal and Child Public Health Agencies Prioritize Women’s Comprehensive Health Needs? Maternal and child health experts within public health are beginning to acknowledge the intimate relationship between women’s health and the well-being of children and families (19 –22). The importance of integrated, comprehensive care for women to improve perinatal outcomes is one of the most politically powerful arguments for expanding the scope of women’s health initiatives within MCH agencies (22,23). When women do not receive comprehensive care prior to pregnancy, they may enter pregnancy with unaddressed medical and social risk factors that compromise the health of both infant and mother. McCloskey and Wise (22) reviewed the results of epidemiologic studies showing that premature births, the largest contributor to low birth weight and infant mortality in the United States, are related to conditions best addressed before pregnancy begins. The authors (22) highlight chronic medical conditions of the mother, prior adverse reproductive outcomes, abusive relationships, inadequate social conditions and nutritional resources, smoking and alcohol abuse requiring long-term interventions, and long-standing infections before pregnancy. Qualitative evidence also demonstrates that comprehensive women’s health care is essential for healthy birth

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outcomes. For example, in one infant mortality review (23), 73% of the infant death cases were preceded by fragmentation and discontinuity of health care over time, even among women with high-risk histories who might have benefited from interconceptional care; in 50% of the cases, women had severe social risks that were unrecognized or unmatched by needed services; in 40% of the cases, mothers had repeated unintended and closely spaced pregnancies, often preceded by sexual abuse histories; and in 38% percent of the cases, mothers, particularly women of color, voiced dissatisfaction with the interpersonal aspects of health care (23). These study results prompt the investigators (23) to recommend implementation of a system of comprehensive and continuous primary care for women, which involves interdisciplinary care teams and community-based health workers. Because the health and welfare of families relies on healthy mothers (19), public health agencies have an interest in ensuring the health of women beyond the perinatal period. Katz et al (24) show that the health status of women of reproductive age is more related to their general well-being than their reproductive health. For example, the leading causes of death from 1980 to 1989 for women in Boston aged 15– 44 were accidents, heart disease, homicide, cancer, suicide, and chronic liver disease. The investigators (24) also demonstrate significant racial disparities in mortality rates among women of reproductive age. The need for MCH agencies to address the comprehensive health needs of women is further underscored by new welfare and immigration policies that may adversely impact women’s health status. The federal Personal Responsibility and Work Opportunities Reconciliation Act of 1996 (PROWRA), which replaced Aid to Families with Dependent Children (AFDC) with Transitional Assistance to Needy Families (TANF), removed the entitlement status of federal assistance and replaced it with fixed block grants to states. New regulations force recipients to meet certain work requirements, deny assistance to families after 5 years, and give states considerable autonomy in designing their own economic assistance policies and programs (25). These changes have a large potential impact on the health of poor women, particularly chronically ill women, immigrants, women experiencing domestic violence, mothers of children with special health care needs, and adolescents (25–27). Unfortunately, it will be difficult to determine how PROWRA policies affect women, because very few of the welfare reform monitoring efforts are evaluating the impact of the new legislation on the health and wellbeing of women (26 –29). The impact of welfare changes on insurance status, however, has been well monitored. PROWRA legislation severed the automatic link between welfare and Medic-

aid enrollment. Although the eligibility criteria for Medicaid has been expanded, an initial decline in Medicaid enrollment after passage of the welfare reform legislation caused concern that this legislation would negatively impact on the health status of women and their families. A recent study showed that state policies deterring TANF enrollment predicts declines in Medicaid enrollment and increases in the number of women without health insurance (30). The Current Debate: Women’s Health Through the Reproductive Years or Across the Life Span? As awareness of the importance of women’s health in promoting healthy children and families has grown, maternal and child public health agencies have begun to debate their role in addressing the health care needs of women. Although there is a core group that believes the field should remain focused on the traditional populations of childbearing women and children, a growing number of MCH professionals agree that the mission of MCH agencies should be expanded to include the comprehensive health needs of women (20). Whether the mission of maternal and child public health organizations should be limited to women of reproductive age or include a lifespan perspective is not agreed on. For example, the Association of Maternal and Child Health Programs, whose membership consists of programs involved in Title V funding and administration, has changed its mission statement from “mothers” to “women of reproductive age.” The Association of Teachers of Maternal and Child Health, which draws members from Title V focused education programs, has broadened its mission to “women,” implying a life span perspective (20). Bennett (21) argues for a life span perspective. She compares the potential consequences of obstetric (perinatal maternal health), reproductive (obstetric health plus contraceptive and preconceptional health), and women’s health perspectives (inclusive of all women’s health care needs) through an analysis of competing policy options and concludes that a life span, comprehensive women’s health approach is the optimal policy option. First, it does not discriminate against women by reproductive status (valuing women who are not mothers) and also maximizes health care options for women who are childrearing but not necessarily childbearing (including the growing number of extended family members involved in the raising of children). Second, it is an efficient approach for improving both reproductive outcomes and other women’s health indicators through expanded primary care for women. Third, a comprehensive women’s health care system that expresses supportive interest in the health of women as well as the health of their children potentially provides the greatest satisfaction for women and the least

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amount of stigma. Fourth, a women’s health approach offers the possibility of expanding knowledge and practice in many areas of maternal and child health, including the little explored impact of nonreproductive factors on maternal and infant pregnancy outcomes. Fifth, sensitivity to race and class issues are best addressed by a women’s health approach because it provides comprehensive health care options to those who are least likely to receive continuous, quality health care regardless of reproductive status. Finally, a women’s health approach extends the concept of social responsibility for health further than the other models. In contrast to Bennett’s argument for a life span approach, Walker (20) argues that MCH agencies are best positioned to address women’s health through the reproductive years. Although she acknowledges the importance and relevance of women’s health needs throughout the life span, Walker reasons that current policies, research, financial resources, and the structure of existing health care delivery systems preclude MCH agencies from undertaking the responsibility for women’s health programs across all age periods at this time. Such a commitment would require maternal and child health programs to integrate with agencies with whom they have not traditionally collaborated well, such as Medicare and chronic disease prevention programs. It would also require new public health insurance resources for many populations, including uninsured postmenopausal women who are not yet eligible for Medicare. She concludes that the MCH field cannot be accountable for all of family and community health at this time but should embrace a women’s health agenda for those of reproductive age. CHALLENGES IN DEVELOPING COMPREHENSIVE WOMEN’S HEALTH CARE SYSTEMS

Does the Public Health System Have the Capacity to Address Comprehensive Women’s Health Needs? Despite the debate over whether maternal and child public health agencies should be responsible for addressing women’s health needs through the reproductive years or across the life span, there is growing support in the MCH community for some form of an expanded role in women’s health. However, a large gap continues to exist in the public health field between theoretic support for integrating a comprehensive women’s health agenda into maternal and child public health activities and actual public health practice (20). Support for the theoretic concept is reflected in the Association of Maternal Child Health Program and Association of Teachers of Maternal Child Health policy changes mentioned above, the American Public Health Association’s Maternal and Child Health Section’s establishment of a Women’s Health

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Committee in 1997, and the MCHB/Johns Hopkins University collaborative initiative Charting a Course for the Future of Women’s and Perinatal Health (20,21,31). However, there has been very little practical movement of Title V agencies toward these goals. Although state MCH agencies have expressed interest in nonreproductive women’s health services, they have established very few comprehensive approaches to women’s overall health care (7). The State Women’s Health Directory (32) reveals that women’s health services at the state level continue to be noncomprehensive and, for the most part, categorically administered. Even when Women’s Health Offices or Divisions are nominally established within state agencies, they often lack significant funding. This has begun to change over the last year, as the federal Maternal and Child Health Bureau strengthens its commitment to women’s health through the Women’s Health Plan of the Division of Perinatal Systems and Women’s Health (formerly Division of Healthy Start) (15). Included in the plan are “Integrated Comprehensive Women’s Health Services in State MCH Program” grants for state Title V agencies. Grant recipients will establish a centralized coordinating body for women’s health that will build partnerships with community-based organizations, academic institutions, and federal agencies, identify gaps in services, and establish an infrastructure for women’s health services (15).

Financial Access to Comprehensive Health Care Services Lack of financial access to comprehensive health services is one of the most significant barriers to ensuring the health of women. The Commonwealth Fund’s Report on Health Care Access and Coverage for Women (33) documents a disturbing trend in rising numbers of women without any health care coverage. Of particular interest to MCH agencies, young women aged 25–39 were less likely to be insured in 1996 than they were in 1986 and more likely to have public insurance than private insurance (33). Other financial barriers include the following (31): ● Women are more frequently insured as dependents of

spouses or other relatives ● Women more often are employed in part-time posi-

tions, where health benefits are limited. ● Women, especially poor women, spend more out-of-

pocket for health services. ● Nearly one third of poor and near-poor women are

uninsured. ● Medicaid coverage primarily involves only pregnan-

cy-related services. ● Welfare policy changes leave most immigrant women

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without health care coverage and create new challenges in enrolling eligible women in Medicaid. Access is also limited by inadequate service availability and enabling services (31). These problems demonstrate the importance of thoughtful approaches to funding comprehensive women’s health agendas and activities. State MCH agencies can neither practically nor ethically diffuse the limited Title V funding that is currently used to serve pregnant women and children (20,21,34). It is important to acknowledge that framing women’s health priorities as preconceptional issues impacting the future of children may be a more politically feasible strategy for funding and promoting women’s health than advocating for broad definitions that emphasize social conditions. (7,34). Although this approach may not directly address the need for universal health coverage for women today, it can be understood as an initial phase in a long-term strategy for meeting comprehensive health needs. Social policy in the United States is most successfully implemented in incremental steps, with large policy changes occurring in 30-year cycles (34 –36). This suggests that women’s health advocates must have long-term strategies for implementing larger objectives through smaller steps. In this context, Misra et al (37) propose expanding postpartum services as the most effective current strategy for addressing comprehensive women’s health needs. This raises the issue of how midwives can and do meet women’s primary health care needs. As women’s health advocates seek effective strategies for expanding access to comprehensive health services, health care providers may find themselves increasingly responsible for interconceptional care. This potentially provides women with higher quality care and enhances the relationship between provider and client. It also requires midwives, nurse-practitioners, and obstetricians/gynecologists to continue to expand their knowledge of interconceptional primary care issues. Fragmentation of the Health Care Delivery System Even when women have financial access to health care, the health care delivery system is rarely able to offer integrated, comprehensive services. This is a function of major gaps in needed services, as well as fragmentation of the services that do exist. The consequences of this system include inefficiencies in the delivery of care to women, higher costs to the woman, her insurer, and society at large, undue burdens on women in accessing care, redundancies in care, and clinical iatrogenic effects (8). Although these problems have been clearly identified in the literature, the definition of comprehensive care has not been articulated. Access to a wide range of services,

a woman-centered philosophy, and community social and economic empowerment (8) are all discussed as central to the development of effective comprehensive care for women (see Table 3). Gaps in services vary by community and state. Women’s health care needs that are most often unmet include the health consequences of domestic violence, sexual abuse, depression, eating disorders, sexual dysfunction, chemical dependency, the menopause transition, and attention to gender-specific aspects of chronic conditions such as heart disease and diabetes (31). Lack of universally available preconceptional care is major gap in health services for women across the nation. Although no reliable national estimates are available on how many women actually receive preconceptional care, one small study showed that only 11% of a sample of 147 pregnant women had received preconceptional care (38). The separate administration and delivery of existing women’s health care services, particularly reproductive and nonreproductive health services, also prevents access to integrated, comprehensive care for women (7). Current funding mechanisms significantly contribute to the persistence of this system level fragmentation by encouraging administration and delivery of health care by service category rather than within a coordinated, comprehensive system. Funding requirements may mandate some degree of separateness from other programs, fund services only for limited population groups that cannot be integrated into a comprehensive service system for all women, and may require separate and often conflicting program data collection and evaluation processes (39). To complicate these matters, funding for the many individual programs often become available at separate points in time. This makes the coordination process an ongoing challenge both at the state and community level. State public health agencies must address internal organizational and cultural dynamics that arise out of traditional categorical program funding, including fragmented communication channels, disconnected intra-agency organizational structures, and a culture that encourages staff dedication to individual program needs rather than agency-wide program integration goals (39). At the community level, there is often no single point of entry into the system or screening system for referring women between programs. Women access individual services without the benefit or knowledge of the wide range of available services. Providers themselves may be unaware of the myriad of resources available to assist women and their families. Those community agencies that receive multiple service contracts might deal with separate state-level staff, processes, evaluation methods, and data collection tools for each program (39). For example, as described in Table 1, public funding for women’s health care provides resources primarily for

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TABLE 3

Woman-Centered Comprehensive Health Care: Services and Standards Comprehensive health services

● ● ● ● ● ● ●

Women-centered care standards*

Additional health services inclusive of minority women’s health care needs†

● ● ● ● ● ● ● ● ● ● ● ●

Primary preventive services for ● Referral networks for specialty nonpregnant women medical services Family planning services ● Alternative health care options Pregnancy-related care (prenatal, birth, ● Facilities located in nontraditional postpartum) settings Mental health services ● Extended hours of operation Teen services ● Culturally competent care Health education ● Interpreter services Domestic violence prevention and ● Enabling services (transportation, interventions childcare) Case management Outreach services Nutrition services Substance abuse prevention and treatment Mutual respect between women and health professionals Comprehensive care with prevention and wellness focus Multidisciplinary team approach Education as an integral part of women’s health Quality control Diverse and culturally competent provider population that advocates for its clients in the larger health care system Ongoing evaluation that assesses quality of care, access, health outcomes including measures that reflect minority women’s concepts of health and wellness Institutional commitment to diversity and social justice ▪ Minority women in key leadership and policymaking positions ▪ Strategies to solicit input from the communities being served ▪ Mechanisms to incorporate input into institutional operations

* Adapted from: Schaps MJ, Linn ES, Wilbanks GD, Wilbanks ER. Women-centered care: implementing a philosophy. Women’s Health Issues 1993;3:52– 4 (43). † Adapted from: Jackson S, Camacho D, Freund KM, et al. Women’s health centers and minority women: addressing barriers to care. The National Centers of Excellence in Women’s Health. J Women’s Health Gender-Based Medicine 2001;10:551–9 (16).

prenatal and family planning services for low-income women. Because Title V and Title X funds are administered separately at the federal level, many health centers and providers at the community level continue to offer programs that are narrowly focused, time limited, and without coordination between separate services (7). It is not clear where women who visit publicly funded family planning or prenatal clinics receive primary care when they are not pregnant (7). A recent study showed family planning clinics are not receiving managed care contracts to provide primary care, as had previously been hoped (40) Medical education also contributes to the fragmentation of women’s health services. Physicians are not traditionally trained in all aspects of women’s health care, nor are individual providers usually responsible for the comprehensive needs of women (8). Consequently, women of reproductive age may seek health care from a number of sources simultaneously, including both public and private providers, without central coordination of their care. They are likely to see an obstetrician/gynecologist for reproductive health care and another primary care provider for nonreproductive needs (31).

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A wide range of health care models has attempted to address issues of fragmentation in health care services. Managed care models of integrated service delivery are particularly important because they serve 75% of insured women, including those with both public and private insurance (33). Although managed care service coordination has the potential to improve the fragmented nature of health care services for women, issues that potentially perpetuate discontinuities in care must be addressed. These include financial incentives to underserve clients and frequent switching between health care plans (31). Midwifery services potentially play an important role in managed care integrated services systems because they address key managed care goals, including lowered costs, increased patient satisfaction, and improved quality of care (41). Many innovative woman-centered health care models also address the need for comprehensive, integrated care (8,16,42). For example, the National Centers of Excellence in Women’s Health (CoE) are dedicated to the development of integrated and comprehensive women’s health center models (16). In addition to addressing comprehensive health service needs, CoE core program

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areas also include education, research, outreach, and leadership development (16). Other women’s health center models include primary care centers, reproductive health centers, birthing centers, and other specialty services (42). To provide quality of care standards for all women’s health centers, the Jacobson Institute of Women’s Health and the Women’s Health Centers Conference developed a set of philosophical core values that should be central to women’s health center models (43) (see Table 3). WOMEN’S COMPREHENSIVE HEALTH CARE SYSTEMS AND PROVIDERS: MIDWIVES AS EXEMPLARS

The quality of integrated women’s health care delivery models depends significantly on the effectiveness of the health care provider. Midwives offer women a unique model of health care that reflects the goals and aims of the MCH community women’s health agenda, including the public health principles proposed by the MCHB Women’s Health Plan outlined in Table 2 (15) and the standards for woman-centered care stated by the Jacob’s Institute outlined in Table 3 (43). The models of women’s comprehensive primary care advocated by these organizations are exemplified by the profession of midwifery, which focuses on prevention, health education, and family- and community-centered care (6,44). CNMs/ CMs are also a provider type well suited to work within integrated service systems designed to decrease fragmentation in women’s health care because they facilitate collaborative relationships with physicians and other women’s health specialists as part of their core practice structure (44). With a history of caring for vulnerable populations (1,2), midwives also bring an expertise that has contributed to improved health for diverse groups of traditionally underserved women (45). This is particularly important for women served by the public health care system. Excellent health outcomes (46) and potential cost savings (47) are associated with midwifery care for childbearing families and suggest midwifery services might also be effective for women outside the maternity cycle. Perhaps midwifery’s most unique contribution to the future health care of women lies in the profession’s tradition of woman-centered care, which is ideally suited to the aims of MCH programs as they develop women’s health care system models (2,6,48). Because the goal that underscores midwifery practice is empowerment of women, midwifery services emphasize health education and supportive techniques designed to help women make healthy decisions for themselves and their families (6,48). Midwives also seek to empower women and improve health outcomes through the “art of doing nothing well,” which focuses on vigilant assessment,

timely referrals, and emphasis on the normal (48). Therefore, midwifery care offered in an integrated women’s health service system might be an ideal model for provision of comprehensive primary care. The emphasis on “being with woman” associated with midwifery practice might also help further the aims of the MCH field’s women’s health agenda. Rather than maintaining hierarchical relationships that traditionally characterize the medical model of care, midwives create nonauthoritarian relationships and shared responsibility with their clients (2,48). This approach seeks to promote trust and communication between the woman and her provider and may encourage women to access health care and make healthy lifestyle choices for themselves and their families (2,48). Further quantitative and qualitative research evaluating the impact of the relationship-building aspect of the provider-client interaction on health care satisfaction and outcomes, particularly for vulnerable populations, needs to be conducted. This example of how current midwifery practice reflects the goals of evolving public health policy and initiatives for women raises interesting questions about an ideal structure for comprehensive, integrated women’s health care systems. Do systems that coordinate care through a primary care provider give higher quality service than systems that coordinate care by payor? If the primary care provider does coordinate services, how do productivity requirements, communication skills, and the “woman-centered philosophy” of the provider impact the effectiveness of care provided to women and how will these issues be evaluated? If women’s primary care physicians, nurse-practitioners, or physician assistants provide care, how will midwifery’s woman-centered philosophy be addressed in their training? When midwives provide care, should their education programs and national or state certification criteria be expanded to include more in-depth knowledge and training in the nonreproductive aspects of health care? WOMEN’S HEALTH POLICY AND CNMS/CMS

The skills and philosophy that contribute to midwifery’s excellence in the provision of primary health care also make midwives rich resources for policymakers. Because midwives assess holistic health care needs within the context of women’s lives (6) and often build lasting relationships with clients and their families (2), midwives possess a unique breadth and depth of knowledge of women’s lives that is invaluable in all phases of policy development. For example, the focus on health promotion, education, and the empowerment of women could be valuable to policymakers interested in developing women’s health care systems as a strategy for addressing the preconceptional issues impacting infant morbidity and mortality.

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Midwifery’s potential contributions to women’s health care policymaking are especially relevant to the new women’s health policy agenda of the Maternal and Child Health Bureau and emerging state Title V interest in integrated women’s health care systems. Midwifery’s woman-centered primary care practice traditions (6,44) echo the MCHB’s women’s health plan draft vision statement that “envisions a Nation in which all women and their families receive comprehensive, coordinated, supportive, culturally and linguistically appropriate quality health care provided in a family-oriented and community-centered setting that enables them to lead healthy, productive lives” (15). Parallel to this recent interest among federal agencies in the development of a women’s health agenda, the American College of Nurse-Midwives (ACNM) has created a Division of Women’s Health Policy and Leadership. This division started in 1999 with the purpose of documenting and strengthening the role of midwifery in promoting the health of women at the community, state, and national level (49). The Division of Women’s Health Policy and Leadership seeks to develop, implement, and promote public health policy and public information initiatives through the work of five sections, including: ● ● ● ● ●

Policy Development and Evaluation Networking Leadership Development Emerging Issues and Developing Trends Public Information

The MCHB-funded ACNM Maternal Child Health Providers Partnership project is an example of how CNMs/ CMs can contribute to the implementation of maternal and child public health initiatives in the ongoing development of women’s health care policy (3,50). The Providers Partnership was established as a cooperative agreement between two provider organizations (ACNM and the American College of Obstetricians and Gynecologists) and MCHB to improve the service systems for maternal and child health populations. These programs are an opportunity to strengthen communication and cooperation between midwifery providers and the public health care system through grants for collaborative projects (3). The first ACNM agreement involved nine state teams comprised of at least one CNM and one state MCH agency official. Statewide conferences that brought together a wide range of perinatal stakeholders fostered alliances that addressed issues such as transportation, cultural competence, and identifying important maternal and child health issues for individual states (50). The most recent grant under this program that the ACNM is involved in is entitled: THRIVE (Teen Health Requires Interactions, Values, and Education) (50). The THRIVE project uses grant monies to support intergenerational programs that promote healthy behaviors among girls

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aged 10 –14 through parental involvement. Again, CNMs/CMs and state MCH officials will team together to promote communication among adolescent health stakeholders. A parent folder, provider brochure, and other projects have also been developed as part of the project (50). Midwifery education can offer an opportune time for students to become familiar with the women’s health care policymaking process. A recent midwifery master’s degree project provided assistance to the Massachusetts Title V Agency in its innovative process of strategic planning around ensuring integrated and comprehensive health services for women in Massachusetts. With mentoring from the Bureau’s Commissioner, senior management staff, and Boston University School of Public Health faculty, the student designed and implemented a qualitative research project on the perspectives of the Bureau’s women’s health program managers on integrating state-level women’s health programs, created a written report of interview findings for the Assistant Commissioner of the Bureau (39), and presented the findings at the Bureau’s Division Managers’ Meeting. Such a project is an example of how midwifery training in holistic, family- and communitycentered perspectives on women’s health provides insight into the importance of integrated and comprehensive women’s health systems, while simultaneous public health training also provides a future midwife with assessment and analysis skills to promote the effectiveness of midwives in the policy arena. CONCLUSION

Midwives and MCH organizations committed to protecting and improving the health of women and their families share an increasing interest in the development of integrated, comprehensive health services for women. As primary care providers for women, CNMs/CMs must be knowledgeable about public health policy that impacts the provision of those services. The unique expertise midwifery potentially offers women’s health care systems development will be most useful if midwives become active in the shaping of women’s health care systems. They can contribute to the development of future policy through involvement in state and local MCH and women’s health agencies (3), ACNM activities such as the Providers Partnership activities (50), or women’s health policy advocacy groups (13). In the process, midwives will become familiar with effective strategies for impacting health care systems development and advance the visibility and expertise of midwifery in women’s health care policy. Support for the author’s MCH Leadership Program Field Practice Placement at the Massachusetts Bureau of Family and Community

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Health was provided by training grant 2 T76 MC 00017 from the Maternal and Child Health Bureau, Health Resources and Services Administration, DHHS. The author gratefully thanks Dr. Lisa Paine for her mentorship during the leadership program field practice experience and for her guidance in the development of this article. The author also expresses special thanks to Professor Mary Barger of the Boston University Nurse Midwifery Education Program for her role as directed-study advisor in developing the original student report and for her generous support in the submission of this article. Thanks also for their guidance during the field practice experience to Janet Leigh and Assistant Commissioner Sally Fogerty of the Massachusetts Bureau of Family and Community Health and to Drs. Eugene DeClercq and Lois McCloskey of the Boston University School of Public Health.

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BACK PAGE QUIZ ANSWERS 1. Mary Breckinridge 2. Hattie Hemschemeyer 3. Ernestine Wiedenbach

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REEINTRODUCING OUR MIDWIFERY PIONEERS 4. Sister Theophane Shoemaker (AKA Agnes Reinders) 5. Maude Callen 6. Marion Strachan

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