By Susan Wysocki and Susan Scanlan
It’s not surprising that women are confused about the recently changed recommendations for cancer screening and prevention. New guidelines from the American College of Obstetricians and Gynecologists (ACOG) – the leading medical group that provides health care for women – say women should wait longer to begin cervical-cancer screening and that they should be screened less frequently. On the heels of similar changes to breast-cancer screening guidelines, it’s understandable that many women might see this as a step backward.
On the contrary, the new cervical-cancer screening recommendations reflect advances in our understanding of this disease and in tools now available to prevent it. More importantly, they present an opportunity to educate women about the significant opportunity we have to further prevent – if not eliminate – cervical cancer.
New ACOG screening guidelines recommend women should begin getting Pap tests at age 21 (as opposed to within three years of becoming sexually active) and that, from ages 21 to 29, most women should have Pap tests every two years instead of annually. Additionally, screening for women 30 and older with a history of normal Pap test results now moves to every three years.
To understand the rationale for these changes, it’s important to first know how the disease develops. Cervical cancer is caused by “high-risk” types of the human papillomavirus (HPV), a common sexually transmitted infection. Most women will have HPV at some point in their lives, but their immune systems will typically clear the virus without symptoms or treatment. HPV infections that persist over time – typically many years – can cause cell changes that can potentially lead to cervical cancer. Because cervical cancer is slow-growing, it generally allows ample time for screening to detect problems that can be treated before the cancer can develop. The majority who die of cervical cancer in the U.S. have either never been screened or have not been screened in many years.
A Pap test is the traditional means of screening for cervical cancer. It involves examining cervical cells under a microscope to detect abnormalities that can then be treated, if necessary. Since its use became widespread 60 years ago, the Pap test has helped to significantly reduce cervical cancer rates. So, if the Pap test has been such a success, why change the guidelines? First, newer research shows that cervical cancer is extremely rare in women under 21. Cervical abnormalities among sexually active girls in this age group are common, but they typically go away on their own. Newer studies, however, show that treatment for these abnormalities that would most likely resolve themselves can cause later pregnancy complications, such as premature birth. This is one instance in which treatment can cause more harm than good. By delaying the start of screening, we can hopefully avoid unnecessary treatment.
The rationale for less-frequent screening is similar. Evidence shows that screening with a Pap test every year does not offer any additional benefit over screening every two or three years. Waiting longer between screenings can help avoid unnecessary treatment of abnormalities that likely will go away on their own.
Also, new technological advances offer women 30 and older – the group most at risk for cervical cancer – more protection against this disease. For these women, an HPV test is now available and uses molecular technology to determine whether HPV is present. An HPV infection that continues for years is what leads to increased risk of developing cervical cancer. If an HPV infection is found, a woman can be monitored more closely by her clinician. A negative HPV test in tandem with a normal Pap test can give a clinician and her patient increased reassurance that the woman is not at risk of developing cervical cancer for at least the next three years. The HPV test also is used for women of all ages to help clarify inconclusive Pap test results. The HPV test is not used routinely in women under 30 because HPV is so common in this age group that a positive HPV test could lead to unnecessary treatment.
While screening is critical to preventing cervical cancer, two HPV vaccines – the first-ever vaccines to fight a cancer – are now FDA-approved and offer significant potential to help reduce cervical cancer rates.
Remember, these new screening recommendations are simply guidelines and that clinicians, in conjunction with patients, need to determine the most appropriate cervical-cancer prevention approach for each woman. These new guidelines provide an opportunity for more conversation on this issue between women and their health-care providers. After all, few things are better for women’s health than educated and empowered patients.
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Wysocki is president and CEO of the National Association of Nurse Practitioners in Women’s Health. Scanlan is chair of the National Council of Women’s Organizations.
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Copyright (C) 2009 by the American Forum. 12/09
By Anne R. Davis, MD, MPH
Every day, I hear from another woman who is losing her job and her health insurance. Every day, I worry. As an obstetrician/gynecologist, I know firsthand what can happen when a woman can’t afford reproductive health care, whether she has lost her insurance or her insurance doesn’t cover women’s basic needs. Cervical cancer develops unnoticed. Pregnant women go without critical prenatal care. Sexually transmitted diseases progress unchecked. We see the results in the emergency room.
Congress must give women a better shot at staying well. Health care reform must change the rules: Health insurance must be affordable to all women, and the insurance we buy must cover our reproductive health care.
In my own life, I’ve always had good health insurance. I go to my ob/gyn each year for a well-woman exam, my birth control is covered, and my hospital bills were paid when I had my two children. These are medical fundamentals -- women’s health care 101-- yet I consider myself lucky to have them. Too many women are not as fortunate. According to the Guttmacher Institute, more than one in four women or their partners have lost their jobs or health insurance in the past year. The institute also reports that one in four women delayed an ob/gyn visit in the last year to save money.
Since the recession began, dozens of women have made emergency appointments with me because they have been laid off and are on the brink of losing their health insurance. They wouldn’t bother if they didn’t depend on the prescriptions and treatments I provide. I always talk to them about how to get emergency care if the need arises, assuring them that I will help them navigate the system. Then we cross our fingers.
Melinda came to see me just before she lost her job and her insurance. She had large fibroids—benign tumors—in her uterus that made her bleed heavily. I prescribed birth control pills, which controlled the bleeding. Then, as sometimes happens with fibroids, the pills stopped working. She bled so heavily she was dizzy and unable to walk. After seven hours of bleeding, Melinda called our office, and we advised her to get to the emergency room immediately. She was in shock; the ER staff gave her a blood transfusion that saved her life.
The next step in her care would be an operation to remove the fibroids. But once Melinda was stable, the doctors discharged her without surgery. Hospitals are required to try to keep every patient alive, but they do not have to provide non-emergency care to people who can’t pay. The staff advised Melinda to apply for Medicaid and schedule the operation once she was covered. But because she receives unemployment benefits, Medicaid deemed Melinda too wealthy for assistance.
Melinda’s bleeding will return. I am her physician, but I can’t give her the treatment she needs. This makes me furious. I am trying to work around the system to get her care, and I know many other doctors who have done the same for patients in crisis. We don’t always succeed.
Sometimes my colleagues and I find ourselves unable to help some women who want to be mothers, like Christine. Christine came in for an IUD. She is 40 and had been pregnant recently. She and her husband have two children, and they wanted to have another baby. Her doctor estimated that even an uncomplicated birth would cost thousands more than they could afford. Christine’s insurance doesn’t pay for labor and delivery, and her family’s income was too high for Medicaid. She had an abortion and then came to me for long-term birth control—neither was covered by her insurance.
Christine’s health insurance policy, like many others, seems to be based on the premise that the reproductive system doesn’t exist, that reproductive health has nothing to do with our overall health. Explain that to her and Melinda.
I am fortunate to have had insurers that cover the essentials for reproductive health. But health care shouldn’t be a matter of luck. All of my patients deserve comprehensive reproductive health services as much as I do.
For too long, women in this country have been sicker than we should be, with far-ranging effects on the jobs we hold, the families we care for, and the society we live in. Congress now has an opportunity to improve the health of women dramatically. Our senators and representatives must put insurance within every woman’s reach.
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Davis, MD, MPH, is the medical director of Physicians for Reproductive Choice and Health and an obstetrician/gynecologist in New York City.
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Copyright (C) 2009 by the American Forum. 11/09
WISCONSIN FORUM
By Dr. Doug Laube
Following President Obama’s historic address to the nation, America is poised for the first dramatic public health achievement of the 21st century.
What makes this moment truly life-changing in every sense of the word is that, for the first time, more women and their families will have coverage than ever before in our nation’s history.
However, if a new national health plan is to fulfill the goal of correcting our fragmented health system and improving America’s health, then it must address the specific health needs of women. That’s why earlier this year, I and a group of medical and public health colleagues contributed to a scientific, data-driven report stating that reproductive health should be an essential part of any national health plan. Our statement was endorsed by 39 deans of schools of public health.
According to the report, issued under the aegis of Columbia University’s Mailman School of Public Health, “a well-woman standard of care -- one that includes access to comprehensive care and services essential to reproductive health -- will ensure that women can attain good health, maintain it through their reproductive years and age well.”
Put simply: without making women’s reproductive health a central component of health care reform, we will not have real reform in the 21st century.
The scientific data point to the compelling need to improve the reproductive health of all Americans. Rates of maternal and infant mortality, low birth weight, unintended pregnancy and sexually transmitted infections are much too high for a nation that is rich in resources and technical competence. Moreover, health problems are concentrated among disadvantaged groups, and these disparate rates have stagnated or worsened over the past three decades.
The good news is that the proposals currently being considered in the House and Senate contain many of the critical elements that will help us address these problems. For the first time, women will be able to participate in a health care system in which:
- Maternity and reproductive health will be part of a basic care package.
- Women won’t be charged more because of their gender.
- An affordability provision will subsidize those who can’t afford insurance.
- Out-of-pocket costs will be capped so that families don’t go bankrupt.
- No American can be denied health coverage because of a pre-existing medical condition, including breast cancer, pregnancy or evidence of “uninsurability” such as being a victim of domestic violence.
- Key preventative tests, like mammograms and pap smears, will be included in basic care.
Nearly one-quarter of all women depend on coverage through their husbands’ employment, leaving them vulnerable to the loss of coverage if divorced or widowed, or if their husbands lose their jobs. Recent years have seen an overall decline in health insurance coverage for women. In 2006, 10 percent of American women received coverage through Medicaid, while 18 percent of women were completely uninsured.
For all of these women, including the 21 million American women and girls currently without health insurance, change cannot come soon enough.
As the president said in his speech, health care reform is not about politics -- it is about shaping the future. But in order to bring about that future, we must show what is at stake and why it is in everyone’s interest to demand coverage that recognizes women’s basic needs and is truly health care, not just sick care.
Without these critical changes, our current system may well top the list of the biggest health care disasters of the 21st century.
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Dr. Laube is Professor of Obstetrics and Gynecology at the University of Wisconsin and Past President of the American College of Obstetricians and Gynecologists.
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Copyright (C) 2009 by the Wisconsin Forum. 10/09
MISSISSIPPI FORUM
By Marsha Meeks Kelly
In another life, I was a public school teacher. English, math and eventually “Skills for Adolescence” were the subjects that consumed my days along with an average of 140 seventh graders.
Every day I worked hard to meet the needs of my students in “inner-city” public schools in Mississippi. I remember the tears of the student who came to me to discuss her pregnancy and how she was going to tell her parents and whether she should get married at 13 years of age.
That year we started a “Peer Ears” program, a peer counseling program, and the next year we started survival skills classes called “Skills for Adolescence.” Too many pregnancies and too many sexually-transmitted diseases forced our school district to incorporate classes to educate our students about their life decisions.
Reading the Centers for Disease Control and Prevention (CDC) report on the sexual and reproductive health of young people was depressing. So little progress has been made here! Twenty years ago several concerned Mississippians formed a statewide coalition to work with the legislature to ensure a comprehensive K-12 health education curriculum, but we still do not have even a pilot program offering students sex education, despite attempts to institute such a program in the 2009 legislative session.
The CDC reports that Mississippi is still among the top states in the nation in the spread of HIV and AIDS among pre-teens. We also have the highest birth rate in the nation for mothers ages 10-14 and 15-17, and have seen a spike in sexually-transmitted diseases. Several government studies have confirmed that about 60 percent of Mississippi high school students are sexually active, but most do not use birth control. The statistics are heart-rending and constitute a moral mandate for action by the leadership of this state.
Mississippi can change such statistics, but like every problem, leaders must step up, understand the issues, look at possible curriculums, get educated and educate our citizens and our youth.
In all my years in public service, I have always been more interested in the opinions of folks in the field rather than critics on the sidelines. I ask the state legislature, the Governor, and the Lieutenant Governor to once more convene a working group focused on comprehensive sex education. This group should include educators, parents, students, social workers and health professionals who deal with youth to ensure that people on the frontlines of teen pregnancy and HIV/AIDS prevention are at the planning table. There are models from other states, like the F.L.A.S.H. program in Washington State, which can be considered.
Young people in Mississippi make tough decisions every day. We can’t be with them all the time, but we can increase their ability to make informed, responsible decisions by giving them the information they need. Comprehensive sex education delays sexual activity and promotes healthier life choices, according to a review of research on the subject by the National Campaign to Prevent Teen Pregnancy.
It is time to set aside emotions and focus on filling the educational gap that jeopardizes the future of so many of our youth. We need a model program that can be set in place across the state. Our young people are counting on us; their health and their future are at stake.
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Kelly is the recently retired executive director of the Mississippi Commission for Volunteer Service.
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Copyright (C) 2009 by the Mississippi Forum 10/09
By Maureen P. Corry, MPH
“I don’t need maternity care.” Sen. Jon Kyl (R-AZ) lobbed this comment against Sen. Debbie Stabenow’s (D-MI) efforts to guarantee maternity coverage as a basic benefit in health care reform. “Your mom probably did,” Stabenow famously shot back. That exchange and the wave of support that followed for Stabenow’s proposals illustrates how out of step Kyl is with a huge majority of Americans, including those in his own party.
Voters across the political spectrum are almost universal in their support for making maternity care an essential health insurance benefit through health care reform, according to a new poll conducted by Mark Mellman and commissioned by the Communications Consortium Media Center and the Women Donors Network. Fully 86 percent of voters strongly support a guaranteed maternity care benefit, and 95 percent believe that women should have the right to decide when to have a child, where to give birth and the health care provider who will attend their birth.
At Childbirth Connection, a 91-year-old national organization advocating high quality, evidence-based maternity care, we are not surprised by these results. We’ve known for years that rapid gains in the quality, value and cost of maternity care are well within reach. Health care reform is our opportunity to ensure that all women and babies get higher quality care with better results, and savings from following best practices can be put toward providing coverage for all.
It’s a fact: Maternity care is an essential component of women’s health care across their lifespan, and it represents a major segment of the health industry. Eighty-five percent of all women give birth, and childbirth is the No. 1 reason for hospitalization. With 4.3 million births per year, maternal and newborn charges are the runaway leader in hospital costs – topping $86 billion in 2006. Employers and private insurers pay for 49 percent of all births, and taxpayers pay for 43 percent. Although the U.S. spends more on health care than other developed nations, our performance lags way behind other countries on quality indicators including low birthweight, prematurity, and maternal death rates. According to the United Nations, 40 other countries have lower maternal death rates.
While the vast majority of childbearing women and their babies are healthy and at low risk, the current style of maternity care is procedure-intensive, costly, and entails unnecessary risk, including elective induction and cesarean surgery. Proven practices that are generally safer and cheaper are underutilized, including continuous support during labor, smoking cessation programs and breastfeeding.
Most Americans agree that access to care must be broadened, quality and value improved and costs reduced. These are achievable goals for maternity care today by simply putting into practice what we already know is good for women and babies from comparative effectiveness research. Many provisions of the health care reform measures passed by committees in Congress are a good first step toward better maternity care in this country, and by extension, better care for all Americans. Key provisions include:
- prohibiting insurers from excluding pregnancy as a pre-existing condition and using past birth experiences (e.g., cesarean section) to justify ineligibility and higher premiums;
- widening access to certified nurse-midwives by eliminating Medicare reimbursement inequities;
- measuring and publicly reporting maternity care performance and using results to improve care;
- paying for family home visits by nurses during and after pregnancy via Medicaid;
- expanding access to primary maternity care by improving Medicaid coverage of free-standing birth centers;
- expanding coverage for prevention and wellness services; and
- offering incentives to maternity care providers under Medicaid to care for underserved women and their families.
America’s women and families are expecting real health care reform. Now it’s time for Congress to deliver.
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Corry is the executive director of Childbirth Connection.
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Copyright (C) 2009 by the American Forum. 10/09
By Donna P. HallA massive, historic and overwhelmingly positive change for women’s lives is coming our way, in the form of the health care proposals now being considered in the House and Senate.
While television networks and newspapers were recently full of commentary and reporting on Rep. Joe Wilson’s loud outburst, the quiet fact remains that when health care reform passes, more women and their families will have coverage than ever before in our nation’s history.
That is no small thing, in a country where an estimated 21 million women lack health insurance, where over half of all medical bankruptcies are filed by female-headed households, and where single mothers and young women dominate the ranks of the uninsured.
The pending reform of the American health care system will -- for the first time ever -- create a seamless, lifelong continuum of care for women, for whom the status quo health care system has been an abject failure.
For the first time, women will be able to participate in a health care system in which:
- They won’t be charged more because of their gender;
- Maternity and reproductive health will be part of a basic care package;
- An affordability provision will subsidize those who can’t afford insurance;
- The system will put a cap on out-of-pocket costs so families don’t go broke;
- No American can be denied health coverage because of a pre-existing medical condition, including breast cancer, pregnancy or evidence of “uninsurability” such as being a victim of domestic violence; and Key preventative tests, like mammograms and pap smears, will be included in basic care.
According to a report published by Columbia University’s Mailman School of Public Health, “a well-woman standard of care -- one that includes access to comprehensive care and services essential to reproductive health -- will ensure that women can attain good health, maintain it through their reproductive years and age well.”
This is good news for everyone -- not just women -- because the inability of the current system to adequately serve women’s health care needs has come at a staggering expense that is borne by everyone. One recent study estimates that women’s chronic disease conditions cost hundreds of billions of dollars. The direct costs of women’s cardiovascular disease, which impacts 43 million American women, are estimated at $162 billion annually. The direct medical costs of diabetes on women totals over $58 billion. The direct medical costs of osteoporosis, which impacts 8 million women, are estimated at nearly $14 billion annually. The direct medical costs of breast cancer are estimated at $9 billion.
Of course, it should surprise no one that any proposal that addresses women’s reproductive health comes with a vociferous debate on the subject of abortion coverage. The House Education and Labor Committee has effectively addressed this issue by adopting an “abortion neutrality” approach -- that is, by allowing private insurance plans to continue to decide whether to cover abortions (nearly 90 percent of them already do) and by maintaining existing restrictions on public funding for abortions. Onerous amendments that would have denied coverage even for private health insurance plans have already been defeated.
A number of national polls have shown that Americans strongly believe that health insurance should include the full range of women’s reproductive health services and that medical experts – not politicians -- should decide the details of a benefits package. The current bills in committee reflect that view.
By insuring coverage of prevention and basic health services like maternity benefits, the proposed reforms will create a system that provides health care, not just sick care, for women and ultimately all Americans.
That news may not be as exciting as a heckling Congressman -- not to mention a finger-chomping activist and gun-toting firebrands -- but it’s an enduring, important, positive change that will be with us long after the headlines have faded.
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Hall is the President and CEO of the Women Donors Network based in San Francisco, California.
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Copyright (C) 2009 by the American Forum. 10/09
TEXAS LONE STAR FORUM
By Margery Engel Loeb and Camille D. Miller
Some of the health care reforms, now being considered in Congress, hold the key that will open the door. We can look forward to a world in which more women and their families have coverage than at any time in our nation’s history. In Texas, there has long been bipartisan, grassroots support for health care for women and children.
For Texas women, and the 21 million women across our nation without health insurance, that will be a truly life changing -- and in many cases, lifesaving -- moment.
Imagine a system in which, for the first time ever, women won’t be charged up to 45 percent more than men for identical coverage, and maternity and reproductive health will be part of a basic care package.
The reforms will also include coverage of important preventative tests like mammograms. And they will put a stop to the shameful practice of denying health coverage because of “pre-existing medical conditions” such as breast cancer and pregnancy, or evidence of “uninsurability” such as being a victim of domestic violence.
The inclusion of women’s health needs is so essential to the health of all Americans that the deans of 39 of America’s 50 schools of public health -- including the deans at University of North Texas and Texas A&M -- have endorsed a scientific, data-driven report by Columbia University’s Mailman School of Public Health stating that such treatments and services should be part of any national health plan.
According to the report, “a well-woman standard of care -- one that includes access to comprehensive care and services essential to reproductive health -- will ensure that women can attain good health, maintain it through their reproductive years, and age well.”
By ensuring coverage of prevention and basic health services like maternity benefits, the proposed reforms will create a system that provides not just “sick care” but true health care for women and ultimately for all citizens of our nation.
In these tough economic times, such changes can’t come soon enough to Texas. According to a report released recently by Families USA, a nonpartisan consumer advocacy group, family health care premiums for Texas workers rose about four and a half times faster than earnings from 2000 through 2009. That troubling figure may help explain why Texas also has the highest number of residents in the nation lacking health coverage (26.3 percent).
In fact, according to an analysis of U.S. Census data by experts at Baylor University, the counties with the six largest Texas cities ranked the worst in the nation in terms of working-age people without insurance. Houston’s Harris County tops the list with 37.6 percent of working-age adults under 65 lacking health coverage. Dallas County is a close second with 33.3 percent uninsured. Bexar, Travis, Tarrant and El Paso counties don’t fare much better.
Texas has the infrastructure, the innovation and the expertise to provide top-quality care for all of its citizens. Now all that’s needed is for our elected officials to help Texas live up to its world-class reputation for cutting-edge medical care by ensuring that Texans have affordable access to that care. In doing so, they will be making history for women and putting the keys to good health into the hands of all Americans.
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Loeb, a member of the Women Donors Network and on the steering committee of their "Moving Forward" initiative on reproductive and other health issues, lives in Victoria. Miller, president/CEO of Texas Health Institute, lives in Austin.
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Copyright (C) 2009 by the Texas Lone Star Forum. 10/09
GEORGIA FORUM
By Ginny McNulty
Kids returning to school might find their lessons haven’t changed all that much from last year. That includes their school-sponsored sex education classes. Even though last spring President Obama ended federal funding for abstinence-only-until-marriage programs -- many of which were proven ineffective in delaying sexual activity – not much has changed yet in Georgia.
During the last school year, I spoke at numerous presentations at my high school to raise awareness about HIV/AIDS. I was repeatedly shocked at how little my fellow classmates knew about HIV/AIDS. I was asked on more than one occasion if HIV is transmitted by simple skin to skin contact. Before doing the presentations, I assumed that the students would know the majority of the information I was giving them. I was wrong.
Students repeatedly asked me about the effectiveness of condoms as protection against HIV infection. Unfortunately, I was unable to answer these curious students because school policy prohibited it. My school employed an abstinence-only policy, which extremely hindered me in giving potentially life-saving information to my classmates. On one occasion, one student confronted me during my presentation when I talked about abstinence and not about condoms. It was difficult for me to continue doing presentations after that incident because I whole heartedly agreed with him.
As a senior in high school I joined the Teen Action Group (TAG) -- Planned Parenthood's teen peer health educators -- because I wanted to empower myself and my fellow teens on matters of sexual health. Now, I see first-hand how responsive teens are to complete and accurate information. Young people are thirsty for knowledge and recognize how important this information is to their lives. I have seen how well teens respond to messages from other teens, often even better than they do with adult educators. For many of my peers who have only had ineffective programs in their schools, I am thankful that peer educators like me and the TAG group will continue to be sources of good information in our communities.
The goal of this program is to educate young people about delaying sexual activity, good decision making skill and contraception as a way of reducing the number of teen pregnancies in our state. Georgia has the 10th highest teen pregnancy rate in the nation and according to Advocates for Youth, the U.S. "continues to have the highest adolescent pregnancy and birth rates in the industrialized world, although U.S. teens initiate sex at about the same time as their European counterparts." The teen pregnancy rate in Canada is half of that in the U.S. With many teen parents and their children facing significant challenges for the rest of their lives, something more has to be done.
So, I have a few messages from myself and my fellow peer educators. To our parents: we understand why you would prefer that we wait to become sexually active until we're ready to be safe. We understand that the decisions we make now can affect the rest of our lives. We want to know what your feelings are about sex and relationships and we know that sometimes, it can be uncomfortable to talk about it. To schools and policy makers: providing us with 'abstinence-only-until-marriage' programs limits our decision making abilities. Withholding information about safer sex and contraception could put our lives at risk.
President Obama’s actions make it so now funds can only be used for scientifically based programs. This is great news for the next generation of young people. Georgia-schools now just need to implement changes to their programs.
Comprehensive sex education does not send a mixed message to us. We want to discuss the benefits of waiting to become sexually active as well as the ways we can be safe when we do become sexually active. Knowledge is power and by refusing us comprehensive sex education, you are depriving us of the power over our lives and our futures.
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McNulty, age 19, is recent Atlanta-area high school grad and a peer health educator through Planned Parenthood’s Teen Action Group program.
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Copyright (C) 2009 by Georgia Forum. 9/09
