• TABLE OF CONTENTS
HIDE
 Front Cover
 Acknowledgement
 Title Page
 Foreword
 Table of Contents
 List of figures
 List of tables
 Overview
 Mortality
 Morbidity
 Other health concerns
 Reproductive health
 The health care system
 Special concerns
 Data and research needs
 Abbreviations
 Back Cover














Group Title: DHHS publication
Title: Women and health, United States, 1980
CITATION THUMBNAILS PAGE IMAGE ZOOMABLE
Full Citation
STANDARD VIEW MARC VIEW
Permanent Link: http://ufdc.ufl.edu/UF00086818/00001
 Material Information
Title: Women and health, United States, 1980
Series Title: Public health reports
Physical Description: 84 p. : charts ; 26 cm.
Language: English
Creator: Moore, Emily C
United States -- Public Health Service
Publisher: For sale by the Supt. of Docs., U.S. Govt. Print. Off.
Place of Publication: Washington
Publication Date: 1980
 Subjects
Subject: Health Manpower -- Statistics -- United States   ( mesh )
Health Education -- Statistics -- United States   ( mesh )
Health -- Statistics -- United States   ( mesh )
Women -- Statistics -- United States   ( mesh )
Women -- Health and hygiene -- Statistics -- United States   ( lcsh )
Women -- Diseases -- Statistics -- United States   ( lcsh )
Genre: federal government publication   ( marcgt )
bibliography   ( marcgt )
statistics   ( marcgt )
non-fiction   ( marcgt )
 Notes
Bibliography: Includes bibliographical references.
Statement of Responsibility: Emily C. Moore ; Public Health Service, Office of the Assistant Secretary for Health and Surgeon General.
General Note: United States "country paper" on women and health presented at the Mid-Decade World Conference of the United Nations Decade for Women.
 Record Information
Bibliographic ID: UF00086818
Volume ID: VID00001
Source Institution: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: oclc - 07000348

Table of Contents
    Front Cover
        Front Cover
    Acknowledgement
        Acknowledgement
    Title Page
        Page 1
        Page 2
    Foreword
        Page 3
    Table of Contents
        Page 4
        Page 5
    List of figures
        Page 6
    List of tables
        Page 7
        Page 8
    Overview
        Page 9
        Page 10
        Page 11
        Page 12
        Page 13
    Mortality
        Page 14
        Page 15
        Page 16
        Page 17
        Page 18
        Page 19
        Page 20
        Page 21
        Page 22
        Page 23
        Page 24
        Page 25
        Page 26
        Page 27
        Page 28
    Morbidity
        Page 29
        Page 30
        Page 31
        Page 32
    Other health concerns
        Page 33
        Page 34
        Page 35
        Page 36
        Page 37
        Page 38
        Page 39
        Page 40
        Page 41
        Page 42
        Page 43
        Page 44
        Page 45
        Page 46
        Page 47
    Reproductive health
        Page 48
        Page 49
        Page 50
        Page 51
        Page 52
        Page 53
        Page 54
        Page 55
        Page 56
        Page 57
        Page 58
        Page 59
        Page 60
        Page 61
        Page 62
        Page 63
        Page 64
        Page 65
        Page 66
    The health care system
        Page 67
        Page 68
        Page 69
        Page 70
        Page 71
        Page 72
        Page 73
        Page 74
        Page 75
        Page 76
        Page 77
        Page 78
    Special concerns
        Page 79
        Page 80
        Page 81
        Page 82
    Data and research needs
        Page 83
        Page 84
    Abbreviations
        Page 85
    Back Cover
        Page 86
Full Text
ai:--


EWA,


w w -w


,.4... .:..
i.? :. ..






'T T sirEBAorto vm U



tr ~SjK KMWM t UNTE STTS
NO rr -k
P~~"Jr:.;. :, ,.:. .v .: .". .
*ii'il:... :. '. ::,'.::".. !. .

;.;... W O N NIT ...:.:.
MR, ... ... .
't : .:. .:I ",. ; .,. ,.. .:. ;: ".. .
: ,". "!: ,. .,'. ::' :.:-' i "


iq6.: ,, :.: .:. ..i .: : .. ,. .: :. . .
.:. x",,. !;. : :': ... ,..... .. :.; .. .

i ,,! .? : i.:!" .,'" : ...o.: .. : .. i .
:. '.: : [. ; ;:... ;:" : .: .
::i::::.: i : .i :.,: i:: iM .. .i o i
I!J ;` i i' `i : i~ ; :: `'. i~ : :; : i : ..; .: ,.. ,:. "...i .. ..
;',; .::,:',...;. :' ,;' !='.. ',' .'. : ,'.. : :.,, : v i ..:i, '".;::i: v ':'. : -: ; ,," ::., ''.. : ."'''': .
.. ,.. :.:.... ,., .,..... ,,., ..:. .: ... .. ..:.... .: . .
......... ~ ~~.. .. .... .... ~i ...: ...... ..... ...' "
!. .:.? ,'>, :.,..E : ''] :&:9 ':: ,. ',.L '". "..: i: ~ :;: .. ': % .,. f ,, .. f ...I'

.... ~ ~ ~ ~ ,. ;.:.: .:., I : "


1980







Acknowledgements

More than 50 women's organizations contributed to
this report by suggesting topics for inclusion or em-
phasis or by offering critical comments on an early
draft. The wide range of their interests and expertise
is hopefully reflected in the final outcome.
For his extraordinary support, encouragement, and
valuable suggestions, I am especially grateful to Irvin
M. Cushner, MD, who was Deputy Assistant Secre-
tary for Population Affairs in the Department of
Health, Education, and Welfare, during the prepara-
tion of this report. His insistence on the importance of
the topic of women's health provided the essential
impetus for the preparation of the report.
For numerous helpful criticisms, I thank Juel Janis,
PhD, special assistant to the Assistant Secretary for
Health, Department of Health and Human Services
(DHHS). Eve Soldinger provided research assistance
in the early stages of the report's preparation. Ruth
Galaid, from the Office of Population Affairs, Judith
Rooks, from the Office of the Assistant Secretary for
Health, and Ruth Segal, from the Secretary's Advisory
Committee on the Rights and Responsibilities of
Women, helped with the final editing. In addition, many
unnamed persons in the various agencies of DHHS
(Health Resources Administration, Health Services
Administration, Center for Disease Control, National
Institutes of Health, Office of the Secretary, Food and
Drug Administration; and Alcohol, Drug Abuse, and
Mental Health Administration) contributed with com-
ments, corrections, and additions.
Despite multiple contributors and reviewers, it is
still likely that the report contains errors-if not of
fact, then of emphasis-for these, I accept full re-
sponsibility.


Emily C. Moore, PhD





PUBLIC
=l sports
HEALTH SEP 198SU
A SUPPLEMENT TO THE SEPTEMBER-OCTOBER 1980 ISSUE


WOMAN
AND
HEALTH
United States
1980


Emily C. Moore, PhD

Public Health Service
Office of the Assistant Secretary for Health
and Surgeon General


For sale by the Superintendent of Documents, U.S. Government Printing Office
Washington, D.C. 20402



































































































2 Public Health Reports Supplement








Foreword


In July 1980, delegations representing the world com-
munity of nations convened in Copenhagen, Denmark,
to evaluate the progress made by women in health,
education, and employment during the past 5 years,
and to set goals and make plans to further that
progress in the coming 5 years. This was the "Mid-
Decade" World Conference of the United Nations
Decade for Women, 1980, held half-way through the
10-year period, designated as a time for the entire
world to strive for equality for women and to make
significant efforts to address their problems.

Each country that participated in the conference was
invited to bring "country papers" reporting the status
of women's health, education and employment for
their countries. This special supplement to Public
Health Reports is the United States' "country paper"
on health. While this paper was written by Dr. Emily
Moore, staff from each of the six Public Health Serv-
ice's agencies were extremely helpful in providing data
for this paper and in reviewing the manuscript in
different stages of its development.

This report documents the progress that has been made
in the health status of American women. However, it
also notes many of the health problems which continue
to pose special problems for women, ranging from the
fact that lung cancer will soon overtake breast cancer
as the leading cancer threat to women's lives, to prob-
lems that women face in obtaining needed health serv-
ices or in receiving appropriate treatment.

In considering the extremely useful material which this
report contains it is, in fact, surprising that a document
such as this has not, to date, been prepared. I believe
this report is particularly valuable for several reasons.
First, as we move toward insuring comprehensive
health care for the entire population, it is essential to
have a data base which allows us to identify specific
problems faced by different segments of the population.
This report begins to provide this type of data on
women's health problems which can help us target
future health resources and services more effectively.
Second, because this report looks not only at the status
of women's health, but also at their roles as consumers
and providers of health care, we can identify issues that


can help us develop strategies to address problems that
may affect women in these roles. And, third, the wide
number of topics covered in this report can provide an
agenda for activities that can and should be pursued
by a number of different public and private groups that
have an interest in women's health.

We are publishing this report to share our enlarged
understanding of U.S. women's health issues with the
broader public health community. Let us all accept its
challenge to further improve the health of American
women during the last half of the United Nations
Decade for Women.






Julius B. Richmond, M.D.
Assistant Secretary for Health and
Surgeon General


September-October 1980 3






Contents

Women and Health United States 1980


U.S. DEPARTMENT OF HEALTH
AND HUMAN SERVICES
Patricia Roberts Harris, Secretary
PUBLIC HEALTH SERVICE
Julius B. Richmond, MD
Assistant Secretary for Health
and Surgeon General
HEALTH RESOURCES
ADMINISTRATION
Henry A. Foley, PhD, Administrator
PUBLIC HEALTH REPORTS
(USPS 324-990)
Marian Priest Tebben, Editor
Esther C. Gould, Assistant Executive
Editor
Virginia M. Larson, Managing Editor
Frank Harding, Art Director
Sandra Rogers, Art Production
Opinions expressed are the authors'
and do not necessarily reflect the
views of Public Health Reports or
the Health Resources Administration.
Trade names are used for identifica-
tion only and do not represent an
endorsement by the Health Resources
Administration.
Address correspondence to:
Editor, Public Health Reports
Room 10-44 Center Bldg.
3700 East-West Highway
Hyattsville, Md. 20782
Subscription Information
To subscribe to Public Health Re-
ports, send check or money order-
$3 per single Issue, domestic, $3.75
foreign; per year (6 issues) $15
domestic, $18.75 foreign-to Super-
Intendent of Documents, U.S. Gov-
ernment Printing Office, Washington,
D.C. 20402. All correspondence about
paid subscriptions (for example, re
change of address or failure to
receive an Issue) should also be
addressed to the Superintendent of
Documents.









I


3 Forward O Julius B. Richmond

9 Chapter I. Overview
9 The demographic context
10 Mortality
10 Morbidity
11 Special health problems
12 Reproductive health
13 The health care system
13 Women with special health needs
13 Data and research needs
13 The future

[4 Chapter 2. Mortality
[4 Life expectancy
14 Mortality rates from all causes
15 The four leading causes of death
15 Diseases of the heart
18 Cancer (malignant neoplasms)
!0 Cerebrovascular diseases
!1 Accidents
!1 Recent trends in sex differentials in mortality
!2 Causes of death of concern to women
12 Breast cancer
!5 Cancer of the genital organs
!5 Cancer of the respiratory system (mainly lung cancer)
!5 Deaths from pregnancy, childbirth, and the puerperium and from fertility
regulation
!8 Diabetes
!8 Homicide and suicide

i9 Chapter 3. Morbidity

i3 Chapter 4. Other Health Concerns
13 Environmental health
13 Occupational health
15 Safety in the home
16 Substance abuse
16 Alcohol
16 Drugs: illicit and legal (prescription and nonprescription)
17 Illegal drugs
17 Legal drugs (prescription)
17 Legal drugs (nonprescription)
17 Smoking
19 Cosmetics
0 Rape
41 Battered women
Q2 Sexual child abuse
12 Mental health and well-being


4 Public Health Reports Supplement







42 Sex differences in mental disorders
43 Sex roles and mental disorders
43 Traditional and alternative treatment approaches
45 Sex differences in "general well-being"
48 Chapter 5. Reproductive Health
48 Menstruation
48 Fertility regulation and birth planning
49 Infertility and childlessness
49 In vitro fertilization
50 Contraception
51 Sterilization and sterility
52 Abortion
53 Unintended (unwanted and mistimed) births
54 Premarital conceptions and out-of-wedlock births
54 Family planning services
55 Population research
56 Pregnancy and pregnancy outcome
56 Prenatal care
56 Technology used during the prenatal period-ultrasound, X-rays, and
amniocentesis
57 Obstetrical practices
59 Lactation
59 Pregnancy outcome
60 Teenage pregnancy
62 Pregnancy in women after age 35
63 Hysterectomy
63 Estrogen use
63 DES
64 Estrogen-replacement therapy in menopause
64 Sexually transmitted diseases (STD)
65 Education, counseling for reproductive health
67 Chapter 6. The Health Care System
67 Women as planners and policymakers
69 Women as health care providers
70 Women as consumers of health care
70 Use of service
71 Insurance
72 Access to health care
73 Consumer-providers
73 Disease prevention and health promotion
74 Sports and exercise
74 Nutrition
75 Obesity
76 Self-care
77 Women's alternative health care
77 Women as "family health care providers"
79 Chapter 7. Special Concerns
79 Disabled women
80 Older women
81 Rural women
81 Lesbian women
82 Racial and ethnic minorities
83 Chapter 8. Data and Research Needs


September-October 1980 5








List of Figures


16 1. Life expectancy by sex, 1930-77
17 2. Population profile of the United States, 1978
17 3. Crude and age-adjusted death rates, per 1,000
population, 1930-77
17 4. Age-adjusted death rates by sex and race,
1900-77
20 5. Age-adjusted death rates for ischemic heart
disease, by race and sex, United States, 1950-76
20 6. Death rates and age-adjusted death rates for
malignant neoplasms, by sex, 1950-75
21 7. Death rates and age-adjusted rates for the
female population for malignant neoplasms, by
race, 1950-75
22 8. Age-adjusted death rates for white females for
leading sites of malignant neoplasms, United
States, 1950-75
23 9. Age-adjusted death rates for all other females
for leading sites of malignant neoplasms, United
States, 1950-75
26 10. Maternal mortality rates, by race, 1976
30 11. Number of work-loss days per currently em-
ployed person per year, by sex and age, United
States, 1975
34 12. Eight-year incidence of coronary heart dis-
ease (CHD) by occupation, marital status, and
children among working women aged 45-64 years
38 13. Age-adjusted death rates from chronic ob-
structive lung disease in women, rate per 100,000
38 14. Age-adjusted death rates from cancer in
women
38 15. Percentage of adults who smoke
39 16. Percentage of adolescents who smoke
39 17. Risks from smoking during pregnancy
42 18. Percent of persons rating themselves on degree
of well-being, by sex, 1971-75
43 19. Percentage of persons aged 25-74 responding
to "Have you been bothered by nervousness or
your nerves in the past month?" by sex
44 20. Percentage of women aged 25-74 responding
to "Have you been bothered by nervousness or
your nerves in the past month?" by work status
44 21. Percentage of persons aged 25-74 responding
to "Have you felt you were under any strain,
stress, or pressure in the past month?" by sex
45 22. Percentage of women 25-74 years responding
to "Have you felt you were under any strain,


stress, or pressure during the past month?" by
work status
45 23. Percentage of persons aged 25-74 responding
to "Have you been anxious, worried, or upset
during the past month?" by sex
46 24. Percentage of women 25-74 years respond-
ing to "Have you been anxious, worried, or upset
in the past month ?" by work status
46 25. Mean general well-being scores, by marital
status, within sex group
50 26. Use of contraceptives by race among cur-
rently married women, 15-44 years, 1973 and
1976, in percentages
53 27. Unintended births among ever married
women, 15-44 years, 1973 and 1976
54 28. Trends in Federal support for population re-
search, by major research area, fiscal years
1970-78
55 29. Population research areas with more than $1
million support by Federal agencies in fiscal years
1977 and 1978
58 30. Selected gynecological and obstetrical pro-
cedures per 100,000, 1970-77
59 31. Percent of ever-married women, 15-44 years,
who breast fed their first child, by duration of
feeding, year of first birth, and race, 1973
60 32. Infant mortality rate per 1,000 live births
60 33. Infant mortality rates by race, selected years,
1950-77
61 34. Fertility rates of women 15-19 years, 1920-74
64 35. Reported gonorrhea cases by sex, United
States, 1965-79
68 36. Trends in the number and percent of resi-
dencies filled by women and blacks for selected
years, 1968-77
69 37. Women as a percent of first-year enrollees in
United States medical schools, 1969-76
81 38. Proportion of women with unmet needs for
abortion services, by selected characteristics, fiscal
year 1977


6 Public Health Reports Supplement








List of Tables


16 1. Remaining life expectancy at birth and at 65
years of age, according to race and sex, United
States, selected years, 1900-78
18 2. Life expectancy at birth by rank according to
sex, selected countries, 1976
18 3. Age-adjusted mortality rates (deaths per 1,000
population) by race and sex, selected years
1935-77
19 4. Age-adjusted death rates and average annual
percent change, according to leading causes of
death in 1950, United States, selected years
1950-77
19 5. Death rates per 100,000 population due to all
causes, by race, sex, and age, 1977
20 6. Age-adjusted death rates per 100,000 popula-
tion for diseases of the heart, by sex and race,
selected years, 1950-77
20 6A. Percent decline in age-adjusted death rates
for diseases of the heart over three intervals, by
sex and race
21 7. Age-adjusted death rates per 100,000 resident
population for malignant neoplasms, by sex and
race, selected years, 1950-77
21 7A. Percent change in age-adjusted death rates
for malignant neoplasms over three intervals, by
sex and race
21 8. Age-adjusted death rates per 100,000 popula-
tion for cancer of the respiratory system, by sex
and race, selected years, 1950-77
21 8A. Percent increase in age-adjusted death rates
for cancer of the respiratory system over three
intervals, by sex and race
24 9. Deaths per 100,000 females from uterine can-
cer, all ages, by race: crude rates for 1950 and
1975; age-adjusted (to 1950) rates for 1977
25 10. Incidence of uterine cancer: cases per 100,000
females of all ages, by race: 1947, 1969, and
1973-77
26 11. Estimated number of deaths related to repro-
duction, by age groups, United States
27 12. Mortality associated with pregnancy and chil-
dren, legal abortion, use of oral contraceptives (by
smoking status) and IUDs, by age groups
27 13. Relative risk of death, by regimen of fertility
regulation and age groups
27 14. Age-adjusted death rates from diabetes, by
selected years, sex, and race, 1968-77


28 15. Age-adjusted death rates per 100,000 popula-
tion for homicide, by sex and race, selected years,
1950-77
28 16. Age-adjusted death rates per 100,000 popula-
tion for suicide, by sex and race, selected years,
1950-77
30 17. Self-assessment of health and limitation of ac-
tivity, by sex, 1977
31 18. Persons 18-74 years with serum cholesterol
levels of 260 ml per 100 mg or more, by sex,
1960-62 and 1971-74, in percentages
32 19. Percent of persons 18-74 years with elevated
blood pressure, by sex and age, 1960-62 and
1971-74
45 20. Mean total general well-being (GWB) scores,
by education and income within sex
45 20A. Mean general well-being scores adjusted for
differences in total GWB by educational level
within sex at three intervals of family income
50 21. Percentage of currently married couples, wife
15-44 years, who are sterile, 1973 and 1976
51 22. Percentage of currently married couples, wife
15-44 years, who are sterile or using contracep-
tion, 1973 and 1976
56 23. Federal support for population research,
selected topics, 1973-78, in millions of dollars
56 24. Median number of prenatal visits in metro-
politan and nonmetropolitan areas, by educational
attainment of the mother and race of the child,
1975
57 25. Percentage of live births attended by physi-
cians in hospitals, by race, selected years, 1940-77
60 26. Infant mortality rates (infant deaths under 1
year per 1,000 live births) by race, 1970-77
62 27. Infant, neonatal, and postneonatal mortality
rates (deaths per 1,000 live births) according to
race, United States, selected years, 1950-77
62 28. Infant mortality per 1,000 live births, by race
and residence
63 29. Estimated rates of Down's syndrome in live
births by 1-year maternal age intervals for
mothers aged 30-44, white live births, upstate
New York, 1963-74
64 30. Venereal disease cases per 100,000 population,
selected years, 1950-77
68 31. Female representation in senior administrative
positions in U.S. medical schools, 1955-78


September-October 1980 7






74 32. Major differences in the needs of the con-
cerned and the complacent, in percentages
74 33. Percent distribution of women 17 years and
over by whether they had ever had a breast ex-
amination or Papanicolaou test, by age group,
1973
76 34. Percentage of obesity among persons 20-74
years, by sex, race, age, and poverty level, United
States, 1971-74


8 Public Health Reports Supplement








Chapter 1. Overview


The purposes of this report are to identify a broad
range of health issues that are either unique to women
or of special importance to women and to note the roles
that women play both as providers and consumers of
health care in the United States.

The Demographic Context
In 1978, 51.3 percent of the population (approximately
112 million Americans) were females. Important
changes in the characteristics of the population have
been occurring.

The post-war Baby Boom peaked in 1957, after
which American fertility steadily dropped. Because of
this change in the birth rate, a declining proportion of
the population are young children and an increasing
proportion are persons 65 or older. Because women
live 8 years longer than men on the average, women
predominate among the older population.
Married couples are now delaying their childbear-
ing longer; the average interval between marriage and
the birth of the first child has increased frorn 14 months
in 1960-64 to 25 months in 1975-78. The average num-


ber of children born to currently married women aged
18-34 was only 1.5 in 1978, compared with 2.1 in 1967.
As actual fertility has declined, so has anticipated
fertility, from an average of 3.1 children among cur-
rently married women in 1967 to only 2.3 in 1978.
Among all women (not just those currently married)
in 1978 average expected fertility was 2.1 children, the
number required for natural replacement of the popu-
lation, but it was only 2.0 children, which is below
"replacement" level, among younger women between
the ages of 18 and 24.

Because of changing social norms, the median age
at marriage has been rising; the proportion of persons
over age 14 who have never been married rose from 19
percent in 1960 to 24 percent in 1978.

High rates of separation and divorce have resulted
in a 50 percent increase during the 1970s of households
headed by women. While 11.8 percent of the total
population in 1977 had incomes below the federally
designated poverty level, 31.7 percent of female-headed
households and 51 percent of black female-headed
households were in this poverty status.


Septomber-October 1980 9







Single-person households have also increased dra-
matically (59 percent in the 1970s), from 10.9 to 17.2
million, many of whom are elderly women.

A majority of women (50.1 percent as of January
1979) are now in the labor force. More than 40 percent
of the labor force is female. Even among women with
preschool children at home, 41.6 percent of those with
husbands present and 42.8 percent of those who are
widowed, divorced, and separated now work; 57 percent
of women with school-age children are in the labor
force.

Although women have taken on new roles and new
responsibilities, their traditional role as homemaker has
not been shared equally with men. Women still bear
primary responsibility for housework, care of their chil-
dren, whether sick or well, and care for the elderly.


Mortality

In the United States life expectancy for both men and
women increased faster during the 1970s than in the
preceding 10 years. Women's mortality advantage over
men has increased over the century, although the pace
of increase appears now to be slowing. Life expectancy
for females born in the United States in 1978 is 77.2
years, up from 76.5 in 1975; for males it is 69.5, up
from 68.7 in 1975.

There have been important shifts during this century
in the major causes of death for Americans of both
sexes, with significant increases in deaths from heart
disease and cancer and declines in deaths from influ-
enza, pneumonia, and certain causes of death during
early infancy. The four leading causes of death for
American females, as well as males, are diseases of the
heart, cancers, cerebrovascular diseases, and accidents.
Antibiotics, immunizations, and improved sanitation
and other public health measures have largely brought
communicable infections under control. We are now
challenged by the chronic and often disabling infirmi-
ties of an aging population and by the need to prevent
diseases caused or influenced by environmental or be-
havioral factors. Thus smoking, alcohol abuse, failure
to use automobile seatbelts, poor eating habits, lack of
exercise, violence, emotional problems, stress, occupa-
tional hazards, and environmental pollutants are the
targets of new public health approaches to improve the
health of Americans.

Although cause-specific mortality rates vary by many
sociodemographic characteristics (for example, marital
status, race, education, employment, and economic
status), gender is the most important factor of all.


The threat of death from pregnancy and childbirth,
which was extremely high at the turn of the century,
has declined to a low level. However, disparities in risk
of maternal mortality continue to exist between the
races, and maternal mortality rates in several other in-
dustrialized nations are lower than in the United States.
A similar picture emerges with regard to infant mor-
tality which declined dramatically in this century, par-
ticularly in recent years. However, infant mortality rates
for minorities continue to be higher than for whites,
and the rate in the United States is still higher than in
several other industrialized nations.
Trends in the leading causes of deaths are generally
encouraging, although the picture is mixed. Predictions
that women's entry into stressful prestige jobs would
increase their risk of cardiovascular mortality have not
been realized; women's mortality advantage in this
respect has not only continued, but increased. From
1950 to 1975, cancer mortality (age-adjusted) rose for
men while declining for women; lung cancer mortality
in women is a striking exception. While mortality rates
for lung cancer are still lower for females than for males,
the female lung cancer mortality rate has risen 230 per-
cent in a quarter of a century, a rise attributed mainly
to increased smoking among women.
Breast cancer is another exception; its incidence is
rising slightly (1 in 13 women will develop it at some
time in her life) ; and the mortality rate has been vir-
tually unchanged since the 1930s despite advances in
early detection and treatment. (Mortality has declined
among women under 50 but has risen among women
over 50.)
Between the ages of 35 and 55, breast cancer is the
leading cause of death (other mortality rates are still
relatively low at these ages) ; however, breast cancer-
like all other cancers-is primarily a disease associated
with growing older; the longer a woman lives, the
greater is her risk from dying of breast cancer (along
with increased risks of death from other causes, so that
breast cancer, while constituting a greater risk at 60
than at 40, is outranked at 60 by other mortality risks).
A remarkable decline in cervical cancer mortality has
been attributed to the widespread use of the Papanico-
laou test for screening. By 1973, 75 percent of U.S.
women over age 17 had been tested at least once.
Men are three to four times as likely as women to be
victims of homicide. Even at its peak ages, 45-54, the
suicide rate among females is only half that among
males.

Morbidity
The preceding section presents a positive profile of
American women regarding mortality; not only do they


10 Public Health Reports Supplement







live longer than men, but the mortality differential
between the sexes continues to widen. However, longer
life does not necessarily mean more years of good health.
A variety of indicators point to more severe health prob-
lems for women than for men. Even when pregnancy
and childbirth are excluded, females report more acute
conditions than males; females have a higher preva-
lence than males of chronic diseases; at older ages,
women have more mobility limitations. Psychosocial,
economic, and biological factors interact to affect gender
differences in perceptions of illness, reported rates of
illness, disability days, restricted activity, and utilization
of health services.
Data from the 1977 Health Interview Survey indicate
that most Americans perceived their own health to be
good or excellent; only 12 percent rated it fair or poor.
Sex differentials were minimal overall; 11.0 percent of
men and 12.2 percent of women rated their health as
fair or poor. Especially among persons 65 or older,
women are more likely than men to experience limita-
tion in their activities because of chronic conditions
such as arthritis and hypertension.

Special Health Problems
Not only have the major causes of mortality and mor-
bidity changed greatly over the years, but the range of
recognized problems has widened to include new con-
cerns regarding environmental health, substance abuse,
violence, and mental health. Although these hazards
and conditions may affect men as well as women, in
some instances the impact differs.
Some illnesses and conditions that are caused by,
partially caused by, or exacerbated by environmental
conditions are also related to culturally determined sex
roles-for example, some occupational hazards. Women
predominate in low-paying, nonunionized occupations,
both of which may be associated with increased health
and safety hazards. Stress also appears to be a problem
for women workers, especially related to repetitive,
paced work, limited opportunity, low wages, and
women's dual responsibilities in the home and work-
place. Recent data indicate that coronary heart disease
rates for women who hold clerical jobs, are married,
and have children are almost twice as high as rates for
nonclerical female workers or for housewives. Factors
found to be predictors of coronary heart disease among
clerical workers were suppressed hostility, having a non-
supportive boss, and decreased job mobility. As women's
participation in the workforce has increased, more atten-
tion has been given this aspect of their health. Until
recently, women's occupational health concerns have
been largely unexplored except as their work affected
pregnancy.


Alcohol abuse has long been considered a man's dis-
ease, with treatment efforts directed toward a male
population. Women's abuse of alcohol has often been
denied by friends and family and has gone unrecognized
by health personnel. Research findings on alcoholic men
have been assumed to apply to women as well. Recent
research on alcoholic women has demonstrated the
effects of alcoholism in pregnant women on their off-
spring and indicates that the reasons for women's alco-
hol problems may differ from those of men. The Na-
tional Institute on Alcohol Abuse and Alcoholism is now
funding experimental programs to work with women
alcoholics.
Sixty-seven percent of prescriptions for tranquilizers
and other psychotropic drugs are for women. Differences
in the manner and extent to which physicians prescribe
for men and women may stem from several causes, in-
cluding women's greater frequency of visits to physi-
cians; physicians' greater tendency to perceive women's
morbidity as psychosomatic, especially since women
more frequently report anxiety, stress, and diffuse symp-
toms; and a focus on women in drug advertising and
promotion.
According to surveys conducted by the National In-
stitute on Drug Abuse, use of psychoactive drugs in
conjunction with alcohol is common among women. The
Food and Drug Administration in 1978 found the use
and abuse of minor tranquilizers to be a clear health
hazard, particularly for women. Women are also more
likely than men to use "over-the-counter" legal non-
prescription drugs.
With each successive generation, the smoking char-
acteristics of U.S. men and women have become increas-
ingly similar. Although the onset of widespread cigarette
use among women lagged by 25 to 30 years behind that
of men, the average age at onset of regular smoking
among young women is now virtually identical to that
of young men. Although the prevalence of cigarette
smoking among adult males declined from approxi-
mately 53 percent in 1964 to 38 percent in 1978, the
percentage of adult females who smoke has remained
virtually unchanged at about 30 percent. Further, the
percentage of girls aged 12 to 14 who smoke has in-
creased eightfold since 1968. The lung cancer mortality
rate among women in 1978 was almost three times as
high as it was in 1964. Women who have smoking char-
acteristics similar to men experience overall mortality
rates similar to those of men. If the current trend con-
tinues, it is expected that by 1983 lung cancer will
surpass breast cancer as the leading cancer threat to a
woman's life. In addition, smoking has a synergistic
effect with use of oral contraceptives. The health risks
of the two together are greater than the sum of the


September-October 1980 11







two considered separately. Even though only about one-
third of women who use oral contraceptives smoke, it
is estimated that more than half of all deaths attributed
to use of oral contraceptives occur in women who smoke.
Federal Bureau of Investigation data indicate that the
incidence of rape may be increasing. Several States have
made important changes in their laws regarding rape;
in some, rape is no longer regarded as a sexual crime
but as a crime of assault; some States now recognize
rape by a husband against his wife; laws regarding the
permissible introduction of evidence at a rape trial have
been altered to protect rape victims from further trauma
during the proceedings. At the Federal level, legislation
has been enacted which funds research on rape. The
National Center for the Prevention and Control of Rape
was authorized by Congress and established within the
National Institute of Mental Health in April 1976.
Domestic violence is another form of violence creat-
ing health problems for women. The problem of bat-
tered women is found in a wide variety of communi-
ties, regardless of class, race, or other factors. An Office
of Domestic Violence was established within the De-
partment of Health, Education, and Welfare in the
spring of 1979. Its activities include public informa-
tion, technical assistance, training, and demonstration
projects related to spouse abuse. In addition, grassroots
organizations have established shelters and support
services.
Victims of sexual child abuse, like those of rape and
spouse battering, are also overwhelmingly female. In
1980, $4 million has been allocated specifically for
demonstration projects aimed at preventing and amelio-
rating the effects of sexual abuse of children.
Data from a national sample of 6,900 adults in 1971-
75 found that, overall, men described themselves as more
likely than women to experience positive well-being and
as less likely than women to feel tension, stress, and
anxiety. Black females reported the lowest level of posi-
tive well-being, with more than half reporting moderate
to severe levels of stress. There was virtually no differ-
ence in general well-being reported by upper-income,
highly educated women and men.
Differences between men and women in the incidence
of mental disorders are observed both in diagnostic
data from mental health facilities and from community-
based surveys. When diagnostic data are analyzed by
marital status, unmarried women-single, divorced, and
widowed-show a lower incidence of mental illness
than men in the same categories; conversely, married
women show a higher incidence of mental illness than
married men. In the past decade, these differences be-
tween women and men in the incidence and patterns of


psychiatric diagnosis have led to an examination of the
relationship between sex roles and mental health.

Reproductive Health
Although pregnancy is still an important event in most
women's lives, reproductive health care now encom-
passes a broader concept of psychobiological sexual
health. A number of important developments and
events have occurred that positively affect women's
reproductive and sexual health.
The reduction in high-risk and unwanted pregnancies
and births that occurred in recent decades is a develop-
ment of central importance to individual women, their
families, and the community. By 1976, only 8 percent
of U.S. women who had ever been married and were
at risk of unwanted conception were not using some
form of contraception. Almost 10 percent of fertile-
aged married American women had been surgically
sterilized for the purpose of contraception, and another
10 percent were married to men who had had vasec-
tomies.
In the 1960s and 1970s health activists and leaders in
and out of government stressed the need for increased
research to develop safer contraceptive methods, for
careful monitoring and testing of present methods, for
development of contraceptives appropriate to the di-
versity of women's life circumstances and preferences,
and for new methods of contraception for males.
In 1973 two U.S. Supreme Court decisions made
abortion during the early months of pregnancy a matter
to be decided between women and their physicians. The
number of legal abortions rose dramatically after that
time. In 1978, 1.3 million legal abortions were per-
formed in the United States.
The proportion of pregnant American women who
obtain early prenatal care has been rising. Access to
hospital care for labor and delivery is now available to
nearly all who want it. Although there is general con-
census about the importance of prenatal care, several
issues regarding childbirth care involve a good deal of
controversy, especially the place of birth, the birth
attendant, the social environment in which birth occurs,
and the appropriateness of procedures often used during
labor and delivery. Natural childbirth is now desired by
and available to an increasing proportion of women.
Acceptance of inclusion of the father during labor and
delivery is increasing. There is also a small but growing
number of parents who choose to have their births at-
tended by certified nurse-midwives rather than by phy-
sicians-whether in hospitals, birthing centers, or their
homes. Breast feeding, once the norm in this country,
declined to low levels, but is now being practiced by an
increasing proportion of new mothers.


12 Public Health Reports Supplement







Maternal mortality in the United States declined dra-
matically from more than 600 deaths per 100,000 live
births in the early 1900s to only 9.9 deaths per 100,000
live births in 1978. U.S. infant mortality fell from 20
per 1,000 live births in 1970 to 13 per 1,000 in 1979,
almost a 35 percent drop in 7 years. However, there is
concern about a number of other reproductive health
issues, especially the number of hysterectomies, the high
proportion of deliveries by Cesarean section, and the
long-term effects of the widespread use of estrogens.
High levels of sexually transmitted diseases, out-of-
wedlock births, and births to adolescents are also
problems.

The Health Care System
Women's roles in the health care system have changed
and are bringing about changes in the system itself.
There has been a dramatic increase in the number of
women entering the established health care system as
physicians (the percent of medical schools' entering
classes who are women rose from 9.2 percent in 1969 to
24.7 percent in 1976), and in new nursing roles which
incorporate some functions which were formerly limited
to physicians. The existence of nurse-practitioners pro-
vides many women with an important health care
option. Although the acceptance of both nurse-midwives
and nurse-practitioners was originally based on their
service to rural and inner-city populations without ade-
quate access to physician care, their services are now
available to and sought by a broad cross section of
American women. Insurance reimbursement for services
performed by nurse-midwives and nurse-practitioners
remains an issue. Psychiatric social workers and psychol-
ogists have similar problems of insurance reimburse-
ment for their work in mental health.
In these "provider" roles, women are having an in-
creasingly visible impact on the delivery of health care.
At the same time, women in the roles of consumers are
also bringing about changes in the health care system,
particularly as the women's health movement encour-
ages more informed, assertive patient behavior. A net-
work of alternative women-controlled, women-run
health care centers places women in the role of con-
sumer-provider and has challenged the sensitivity and
appropriateness of some health care providers within
the established system.
Health insurance coverage of women and of female-
specific health problems is currently an important issue.

Women With Special Health Needs
The United States has long been a nation of unusual
cultural, linguistic, and racial diversity. That diversity
has constituted one of the nation's greatest strengths.


Yet discrimination and neglect by majority groups have
resulted in numerous problems for those in the minority,
including health problems. Some of these problems are
shared by men and women within each minority group;
others are unique to women. Some health problems are
shared by all women, regardless of majority or minority
status-and these are the primary focus of this report.
Because data are not adequate to describe the health
problems of some groups of women with special health
care needs, these issues are addressed in only a limited
way in this report.

Data and Research Needs
Women meeting in Houston in 1977 recommended that
data be collected on beneficiaries of all Federal pro-
grams by sex, minority status, and by urban-rural or
metropolitan-nonmetropolitan areas. Access to such
data still constitutes a problem, as evidenced by some
reports on health care that do not include tables by sex.
Many data collected by sex are not published. Often
data are presented by a single variable; it would add to
the understanding of health and health system needs if
sex were analyzed more frequently with other variables.
Some research into problems which affect both women
and men have used only male subjects; the resulting
data often cannot be validly generalized to the female
population. In addition, more research is needed on
certain health problems which affect only women or
which affect women primarily. There is a critical need
for data on the effects on women and infants of preg-
nancy care technologies such as electronic fetal monitor-
ing and Cesarean section. It is expected that increased
research will result in safer, effective contraceptives for
both women and men.

The Future
As the causes of death have shifted from infectious dis-
eases to chronic illness and accidents, future improve-
ment in the health status of this nation will come pri-
marily from changes in personal habits and by people
more actively participating in their own health care.
Women are already playing important roles in these
changes.
In sum, there have been exemplary advances in
health indicators in the United States in recent years.
More Americans now live longer, healthier lives than
ever before. Nevertheless much still needs to be done.
The challenge for the last 20 years of this century is to
continue to improve the level of health for all people
in this country. The United States is fully committed to
the World Health Organization's goal of equality of
access for all to quality health care by the year 2000.


September-October 1980 13








Chapter 2. Mortality


Life Expectancy
Women in most industrialized countries of the world,
including the United States, enjoy a survival advantage
over men. Life expectancy for females born in the
United States in 1978 is 77.2 years, up from 76.5 in
1975; for males it is 69.5, up from 68.7 in 1975 (table
1, fig. 1). This 8-year gap contrasts with a 2-year gap
in 1900 when women had a life expectancy of 48.3 years
and men of 46.3. (Most of the gains in life expectancy
were due to improved survival rates for infants; in
recent years, improvement in survival of adults has also
contributed to increased longevity. Life expectancy at
birth climbed faster from 1970-77 than in the previous
2 decades.) The long-standing disparity between survi-
val of women and men results in a larger number of
women than men at older ages (fig. 2).
Although whites of both sexes had a greater life ex-
pectancy than nonwhites of both sexes until 1970, non-
white females now live longer than white males. The
gender difference has widened as the racial difference
has narrowed (table 1).
Despite encouraging advances in life expectancy in
the United States, there are still a number of other
countries where both men and women can expect a
longer life than in the United States (table 2).

Mortality Rates from All Causes
The crude death rate represents numbers of deaths,
usually per 1,000 population in the case of total deaths,
or per 100,000 population in the case of deaths from a
specific cause. Age-adjusted death rates show what the
level of mortality would be if there were no changes in
the age composition of the population from year to year.
By 1977, the age-adjusted death rate had reached its


lowest level ever in the United States: from 11.6 in
1935 to 6.1 per 1,000 population in 1977 (fig. 3); re-
ductions in mortality occurred for both sexes (table 3
and fig. 4).
There have been important shifts over time in the
major causes of death. The following table illustrates
the large rise between 1900 and 1976 in deaths from
heart disease and cancer (malignant neoplasms) and
declines in cerebrovascular deaths, accidents, influenza
and pneumonia, and deaths in early infancy. The crude
death rates for the 10 leading causes are arranged in
rank order for 1976:

Number of deaths per
100,000 population


Cause of death
Diseases of the heart .............
Malignant neoplasms .............
Cerebrovascular diseases ..........
Accidents ......................
Influenza and pneumonia ..........
Diabetes mellitus ................
Cirrhosis of the liver ..............
Arteriosclerosis ..................
Suicide ........................
Certain causes of mortality in
early infancy ..............


1900 1976


137.4
64.0
106.9
72.3
202.2
11.0
12.5

10.2


337.2
175.8
87.9
46.9
28.8
16.1
14.7
13.7
12.5


All causes .................. 1,719.1 889.6

1 Birth injuries, asphyxia, infections of the newborn, ill-
defined diseases, immaturity, and others.
SOURCE: National Center for Health Statistics: Facts of
life and death. DHEW Publication No. (PHS) 79-1222. U.S.
Government Printing Office, Washington, D.C., November
1978.

These changes are related to the aging of the popu-
lation (thus more people are at risk of diseases specific


14 Public Health Reports Supplement






























to older ages), improved sanitation and pu
and to dramatic changes in life style. For exar
from tuberculosis have declined by 11 pe
1950, and there have been encouraging rec
in deaths from heart disease (table 4).
The female advantage appears at virtually
in life (table 5)--that is, differences in occur
life style and in utilization of health care ir
cannot fully account for this lifelong mo
vantage.

The Four Leading Causes of Death
Despite their greater life expectancy and
tality rates, women die from the same major
do men-namely heart disease, cancer, cere
diseases, and accidents.
The four major causes of death are lea
for both sexes, but in all major categories o
females have lower death rates than males. A
death rates per 100,000 population by sex fo
major causes follow:


Leading causes
Diseases of the heart .......
Malignant neoplasms .......
Cerebrovascular diseases ....
Accidents: ...............
Motor vehicle ...........
Other accidents .........


Males

1968 1977
366 295
156 165
79 54
83 66
43 33
40 32


SOURCE: National Center for Health Stat
statistics of the United States, published annually.

Diseases of the heart. Diseases of the heart
tive rheumatic fever, chronic rheumatic he
hypertensive heart disease, ischemic he;


blic health,
nple, deaths
recent since
ent declines

every stage
pation and


(acute myocardial infarction and angina pectoris), and
other forms of heart disease (endocarditis, congestive
heart failure).
Although men's rates of death from heart diseases
are higher than women's at all ages, women are far
from immune: heart diseases are also the leading cause
of death for women.


Adulthood The importance of distinguishing between crude
)rtality ad- death rates and age-adjusted rates is apparent when
examining trend data by sex; for white females, the
crude death rate from heart disease actually rose from
1950 to 1977, but that was due to the increased numbers
lower mor- of women in the age groups most at risk. Age-adjusted
ir causes as rates (tables 6 and 6a) show declines for both sexes,
brovascular with the most striking advance being a 45 percent
decline from 1950 to 1977 among nonwhite women,
ding killers followed by a 39 percent decline among white women,
.f mortality, a 23 percent decline for white men, and a 20 percent
ge-adjusted decline for black men. (Larger percentage declines
r these four among those who start higher are not surprising, but
nonwhite males in 1950 had the highest rates, followed
by white males; yet it was females of both races who
Females experienced the largest reductions.) Figure 5 illustrates

1968 1977 these age-and-sex trends for ischemic heart disease,
187 143 which contributes 90 percent of the deaths due to dis-
109 110 eases of the heart.
65 44 These declines in heart disease mortality may be due
29 23
15 12 to decreased smoking (only among men), improved
15 11 management of hypertension, decreased dietary intake
of fats, increased physical activity, improved medical
tistics: Vital
emergency services, and more widespread and efficient
use of coronary care units (1).
include ac- The Framingham study (2, 3) in which 5,209 men
art disease, and women were studied for over 25 years, points up
art disease interesting gender differences:


September-October 1980 15








Figure 1. Life expectancy by sex, 1930-77


Age in years


'h


Female


Both sexes


70 .i -

Mole

65 00



60



55

Oi, I I I i ,,,, i I I I I I ,
1930 '40 '50 '60 '70 '80


SOURCE: Final mortality statistics, 1977. Monthly Vital Statistics Report 28: 1, May 1979.


Table 1. Remaining life expectancy at birth and at 65 years of age, according to race and
years, 1900-78 '


sex, United States, selected


Total White All other
Specified age
and year Both Both Both
sexes Male Female sexes Male Female sexes Male Female


At birth
19002 ................... .. 47.3 46.3 48.3 47.6 46.6 48.7 33.0 32.5 33.5
1950 ....................... 68.2 65.6 71.1 69.1 66.5 72.2 60.8 59.1 62.9
1960 ....................... 69.7 66.6 73.1 70.6 67.4 74.1 63.6 61.1 66.3
1970 ...................... 70.9 67.1 74.8 71.7 68.0 75.6 65.3 61.3 69.4
1975 3 ...................... 72.5 68.7 76.5 73.2 69.4 77.2 67.9 63.6 72.3
1976 3 ...................... 72.8 69.0 76.7 73.5 69.7 77.3 68.3 64.1 72.6
1977 ...................... 73.2 69.3 77.1 73.8 70.0 77.7 68.8 64.6 73.1
1978 ....................... 473.3 469.5 477.2 ... ....

At 65 years
1900-02 2 ................... 11.9 11.5 12.2 ... 11.5 12.2 ... 10.4 11.4
1950 ....................... 13.9 12.8 15.0 ... 12.8 15.1 ... 12.5 14.5
1960 ....................... 14.3 12.8 15.8 14.4 12.9 15.9 13.9 12.7 15.2
1970 3 ...................... 15.2 13.1 17.0 15.2 13.1 17.1 14.9 13.3 16.4
19753 ................. ... 16.0 13.7 18.0 16.0 13.7 18.1 15.7 13.7 17.5
1976 3 ...................... 16.0 13.7 18.0 16.1 13.7 18.1 15.8 13.8 17.6
19773 ...................... 16.3 13.9 18.3 16.3 13.9 18.4 16.0 14.0 17.8


1 Data are based on the national vital registration system.
2 Death registration area only. The death registration area increased
from 10 States and the District of Columbia in 1900 to the coterminous
United States in 1933.
3 Excludes deaths of nonresidents of the United States.
4 Provisional data.

SOURCES: Grove, R. D., and Hetzel, A. M.: Vital statistics rates in the
United States 1940-1960. National Center for Health Statistics. DHEW


Publication No. (PHS) 1677, U.S. Government Printing Office, Washington,
D.C., 1968. Vital statistics of the United States, 1970, Vol. II, Part A,
DHEW Publication No. (HRA) 75-1101. Health Resources Administration,
U.S. Government Printing Office, Washington, D.C., 1974; Final mortality
statistics, 1973-1977. Monthly Vital Statistics Report Vol. 25, No. 11, Feb.
11, 1977, DHEW Publication No. (HRA) 77-1120; Vol. 26, No. 12, Mar. 30,
1978, DHEW Publication No. (PHS) 78-1120; Vol. 28, No. 1, May 11, 1979,
DHEW Publication No. (PHS) 79-1120; unpublished data from the Division
of Vital Statistics, National Center for Health Statistics.


16 Public Health Reports Supplement


I~C








Men have about three times the risk of developing
a "major cardiovascular event" before age 60;
"At any level of combined risk factors, women have

Figure 2. Population profile of the United States, 1978


Total


Age (years) 106,502,00
85+
80-84 Male
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4
I I
10 5
(ft


0 112,046,000

Female


0
lilllons)


only about half the risk of men of the same age. This
suggests a biological protection of women during their
reproductive years. The gap in incidence between the
Figure 4. Age-adjusted death rates by sex and race, 1900-77


Deaths per 1,000
population
30


5 10


SOURCE: U.S. Bureau of the Census: Population profile of the United States, 1978,
Current Population Reports, Series P-20, No. 336, April 1979.


O I I I I I I I I
1900 '20 '40 '60 '80


SOURCE: National Vital Registration System, National Center for Health Statistics.

Figure 3. Crude and age-adjusted death rates, per 1,000 population, 1930-77


Death rate


12


Crude
death rate

10


Age-adjusted
death rate
8
8-------------------------------------





6 ..

01 II I, l l i lI I I. I, I I I
1930 '40 '50 '60 '70 '80


SOURCE: Vital statistics of the United States, published annually by the National
Center for Health Statistics.


September-October 1980 17





Table 2. Life expectancy at birth by rank according to sex, selected countries, 1976 1

Country Female Male Country


Switzerland ............. .................... 78.3 72.3 .................. Japan
Sweden ...................................... 78.1 72.2 .................. Sweden
Netherlands ................................ 78.1 71.7 .................. Switzerland
Japan ....................................... 77.6 71.6 .................. Netherlands
France ...................................... 77.6 71.0 .................. Israel 2
Canada ...................................... 77.1 69.9 .................. Italy
United States ................... ............ 76.7 69.7 .................. England and Wales
Australia .................................. 76.4 69.6 .................. Canada
Italy ................. .. ...................... 76.1 69.5 .................. France
England and W ales .................... ...... 75.8 69.3 .................. Australia
Israel 2 ....... ..... ........... ............ 74.7 69.0 .................. United States
German Federal Republic ................... .. 74.7 68.9 .................. German Democratic Republic
German Democratic Republic ................... 74.5 68.1 .................. German Federal Republic


SData are based on reporting by countries. Data for Canada, France, zation, Geneva, 1978; Demographic yearbook 1976. United Nations, New
and Italy refer to 1974; data for the German Federal Republic, Israel, York, 1977; Final mortality statistics, 1976. Monthly Vital Statistics Re-
and Australia refer to 1975. port, Vol. 26, No. 12, supplement 2. Public Health Service, Washington,
2 Jewish population only. D.C., Mar. 30, 1978.
SOURCES: World health statistics, 1978. Vol. 1. World Health Organi-

Table 3. Age-adjusted mortality rates (deaths per 1,000 population) by race and sex, selected years 1935-77


Total White Nonwhite
Year
Both Male Female Both Male Female Both Male Female


1935 ....................... 11.6 ... ... 12.3 9.8 ... 18.5 16.1
1968 ....................... 7.3 9.7 5.6 7.1 9.3 5.3 10.5 12.9 8.3
1969 ....................... 7.3 9.5 5.4 6.9 9.1 5.1 10.1 12.7 8.0
1970 ....................... 7.1 9.3 5.3 6.8 8.9 5.0 9.8 12.3 7.7
1971 ....................... 7.0 9.2 5.2 6.7 8.8 4.9 9.6 12.1 7.6
1972 ....................... 7.0 9.2 5.2 6.7 8.8 4.9 9.7 12.3 7.5
1973 ....................... 6.9 9.1 5.1 6.6 8.7 4.8 9.5 12.1 7.4
1974 ....................... 6.7 8.8 4.9 6.4 8.4 4.7 9.0 11.5 6.9
1975 ....................... 6.4 8.5 4.7 6.1 8.1 4.5 8.5 11.0 6.5
1976 ....................... 6.3 8.3 4.6 6.0 8.0 4.4 8.3 10.7 6.4
1977 ....................... 6.1 8.1 4.5 5.9 7.8 4.3 8.1 10.5 6.2


SOURCE: Table 24 in Facts of life and death. National Center for
Health Statistics, Hyattsville, Md., November 1978, and Vital statistics of

sexes is lost with advancing age" (national data indicate
that the gap narrows and is not "lost" entirely; women
overall maintain some advantage at all ages) ;

The "biologic protection of women [can] be over-
ridden since the wives of men who developed coronary
heart disease had double the risk of those whose hus-
bands escaped it, indicating powerful environmental
influences;"

Although overall cardiovascular and coronary
heart disease mortality was inversely related to the
level of physical activity (the higher the activity, the
lower the risk), this effect is modest compared to other
risk factors and, for women, the picture is less clear
because it is difficult to separate age from level of
activity; and


the United States, published annually.


Persons who developed diabetes had at least a
doubled risk of cardiovascular mortality; the diabetic
female loses her advantage over the male (2).

Cancer (malignant neoplasms). Mortality from cancer
is a mixed picture. Cancer is the leading cause of death
among women ages 30-54. The American Cancer
Society estimates that 388,000 women will be diagnosed
with cancer in 1979, and 180,500 will die from it.
While men (especially black men) have experienced
increases in cancer mortality-28 percent increase be-
tween 1950 and 1977-white women have experienced
an 18 percent decline over the same period-all of the
decline prior to 1970-and black women a 7 percent
decline (tables 7, 7a and figs. 6 and 7).
However, these overall trends mask important differ-
ences by site of the cancer (figs. 8 and 9), by age, and


18 Public Health Reports Supplement








Table 4. Pge-adjusted deuth rates and average annual percent change, according to leading
United States, selected years 1950-77'


causes of death in 1950,


Year All Diseases of Malignant Cerebrovascular All
causes the heart neoplasms diseases accidents Tuberculosis


Deaths per 100,000 resident population


1950 ....................... 841.5 307.6 125.4 88.8 57.5 21.7
1955 ....................... 764.6 287.5 125.8 83.0 54.4 8.4
1960 ....................... 760.9 286.2 125.8 79.7 49.9 5.4
1965 ....................... 739.0 273.9 127.0 72.7 53.3 3.6
19702 ...................... 714.3 253.6 129.9 66.3 53.7 2.2
1975 2 .............. ......... 638.3 220.5 130.9 54.5 44.8 1.2
19762 . . . ... 627.5 216.7 132.3 51.4 43.2 1.1
19772 . . . . ......... 612.3 216.4 133.0 48.2 43.8 1.0

Average annual percent change


1950-77 .................... --1.2 -1.4 0.2 -2.2 -1.0 -10.8
1950-55 .................... -1.9 1.3 0.1 -1.3 -1.1 -17.3
1955-60 .................... --0.1 0.1 0.0 -0.8 -1.7 -8.5
1960-65 .................... --0.6 -0.9 0.2 -1.8 1.3 -7.8
1965-70 .................... --0.7 -1.5 0.5 -1.8 0.1 -9.4
1970-77 .................... --2.2 -2.6 0.3 -4.5 -2.9 -10.7
1975-77 .................... --2.1 -2.3 0.8 -6.0 -0.5 -0.9


1 Data are based on the National Vital Registration System. population of the United States as enumerated in 1940, using 11 age
2 Excludes deaths of nonresidents of the United States. groups.
SOURCE: Division of Vital Statistics, National Center for Health Statis-
NOTE: Age-adjusted rates computed by the direct method to the total tics: selected data.






Table 5. Death rates per 100,000 population due to all causes, by race, sex, and age, 1977


Age group White male White female Black male Black female All other male All other female


Under 1 year ...................
1-4 years ........... ........ .
5-9 years ................... ...
10-14 years .................. .
15-19 years .................. .
20-24 years ................. ..
25-29 years .................. .
30-34 years .................. .
35-39 years .................. .
40-44 years .................. .
45-49 years .................. .
50-54 years .................. .
55-59 years .................. .
60-64 years .................. .
65-69 years .................. .
70-74 years .................. .
75-79 years .................. .
80-84 years .................. .
85 years and over ...............


1,429.7
69.7
38.4
42.5
145.8
190.0
167.3
164.2
219.3
339.7
565.1
925.4
1,440.0
2,338.0
3,436.4
5,233.9
8,104.6
11,597.5
18,041.7


1,094.8
55.0
25.6
25.0
55.2
59.3
61.4
78.3
115.6
191.7
309.7
480.1
726.2
1,144.0
1,632.7
2,634.6
4,603.3
7,494.9
14,039.7


3,038.7
113.6
53.6
55.7
143.0
287.2
412.8
465.8
610.0
862.9
1,206.2
1,765.1
2,472.3
3,565.0
3,937.4
6,699.0
9,886.7
9,853.8
12,030.0


2,509.6
91.0
35.6
28.3
62.0
102.7
143.8
178.2
275.8
440.6
658.4
998.5
1,397.3
1,987.4
2,234.5
4,606.8
7,271.0
6,618.5
9,035.3


2,780.4
108.1
51.6
53.9
145.0
276.6
382.0
415.1
560.8
793.0
1,100.8
1,624.2
2,310.8
3,360.1
3,795.2
6,196.1
8,650.4
8,986.0
11,286.1


2,304.5
87.1
34.3
28.0
62.8
99.1
131.7
165.6
256.1
404.1
599.7
914.5
1,307.5
1,895.0
2,176.1
4,298.6
6,450.8
6,265.0
8,673.5


SOURCE: National Center for Henlth Statistics, National Center for
Heath Services Research: Health Un,;ed States, 1979. DHEW Publication


No. (PHS) 80-1232, Hyattsville, Md., table 8.


September-October 1980 19







Figure 5. Age-adjusted death rates for ischemic heart disease,
by race and sex, United States, 1950-76


Revisions of the International Classification of Diseases
400 Sixth Seventh Eighth

380
White male

300


250
o

SAAll other male
a 200



SAll other female
e
I 150

White female



100 I I I I I i i Il I I l l i I
1950 '55 '60 '65 '70 '75

SOURCE: National Center for Health Statistics: Chartbook for the Conference on
the Decline in Coronary Heart Diseases Mortality. Hyattsville, Md., August 1978.


by race (figs. 8 and 9 and tables 8, 8a). Among all
women, mortality is increasing sharply from lung can-
cer (table 8) and increasing slightly from cancer of the
breast, ovary, pancreas, and large intestine, and from
leukemia; among nonwhite women, mortality is also
increasing somewhat from cancer of the brain. Mortal-
ity is decreasing among all women from cancer of the
stomach and uterus (including the cervix), and among
white women from cancer of the stomach (figs. 8
and 9).

Cerebrovascular diseases. This category includes cere-
bral hemorrhage, cerebral embolism, and cerebral arte-
riosclerosis. The news about this category of mortality is
all good: declines have been seen among both sexes and
all races in recent years, most especially among non-
white women. Female mortality rates are consistently
lower than male rates (table 4 and text table page 15).
Although the popular press carries many articles on
the "expected" increase in cardiovascular mortality
(heart and cerebrovascular diseases) -"expected" be-
cause entry into the labor force of large numbers of
women (some of whom have risen to high-paying jobs)
is presumed by some to result in greater stress and thus
higher incidence of stress-related diseases-this has not
happened.


Table 6. Age-adjusted death rates per 100,000 population
for diseases of the heart, by sex and race,
selected years, 1950-77

White All other
Year Total
Male Female Male Female

1950 ...... 308 381 224 408 343
1960 ...... 286 375 197 368 283
1970 ...... 254 348 168 351 237
1975 ...... 221 308 144 307 195
1976 ...... 217 303 142 303 190
1977 ...... 210 294 137 298 189

SOURCE: National Center for Health Statistics, National Center for
Health Services Research: Health, United States, 1979. DHEW Publication
No. (PHS) 80-1232, Hyattsville, Md., 1980; adapted from table 14.

Table 6A. Percent decline in age-adjusted death rates for
diseases of the heart over three intervals, by sex and race

Sex and race 1950-70 1970-77 1950-77

Total ............... 17.5 17.3 31.8
White male ....... 8.7 15.5 22.8
White female ...... 25.0 18.5 38.8
All other male ..... 14.0 15.1 20.3
All other female ... 30.9 20.3 44.9

SOURCE: National Center for Health Statistics, National Center for
Health Services Research: Health, United States, 1979. DHEW Publication
No. (PHS) 80-1232, Hyattsville, Md., 1980; adapted from table 14.

Figure 6. Death rates and age-adjusted death rates for
malignant neoplasms, by sex, 1950-75

Male Female
Death rate per
100,000 population
200



180

Death rate






140 Death rate
Age-adjusted
death rate

120 Age-adjusted
death rate



1001 il I 1 I I I
1950 '60 '70 '50 '60 '70

SOURCE: Statement by D. Rice, Director, National Center for Health Statistics, be-
fore the Intergovernmental Relations and Human Resources Subcommittee, Commit-
tee on Government Operations, U.S. House of Representatives, June 14, 1977.


20 Public Health Reports Supplement








Figure 7. Death rates and age-adjusted rates for the female
population for malignant neoplasms, by race, 1950-75


White female All other female
Death rate per
100,000 population
160



Death rate
140

Age-adjusted
death rate
120
Age-adjusted
death rate Death rate


100 1 i I I I II I I I I
1950 '60 '70 '50 '60 '70

SOURCE: see figure 6.


Table 7. Age-adjusted death rates per 100,000 resident
population for malignant neoplasms, by sex and race,
selected years, 1950-77

White All other
Year Total
Male Female Male Female

1950 ...... 125 125 131 126 131
1960 ...... 126 142 110 155 125
1970 ...... 130 154 108 185 118
1975 ...... 131 157 107 200 119
1976 ...... 132 159 108 202 119
1977 ...... 133 160 108 206 122

SOURCE: National Center for Health Statistics, National Center for
Health Services Research: Health, United States, 1979. DHEW Publication
No. (PHS) 80-1232, Hyattsville, Md., 1980; adapted from table 17.


Table 7A. Percent change in age-adjusted death rates for
malignant neoplasms over three intervals, by sex and race

Sex and race 1950-70 1970-77 1950-77

Total ............... +4 +2 +6
White male ........ +23 +4 +28
White female ...... -18 0 -18
All other male ..... +47 +11 +63
All other female .... -10 -3 -7

SOURCE: National Center for Health Statistics, National Center for
Health Services Research: Health, United States, 1979. DHEW Publication
No. (PHS) 80-1232, Hyattsville, Md., 1980; adapted from table 17.

Accidents. Accidents are the fourth leading cause of
death, and the first cause among persons aged 1-34
years. About half of these deaths are due to motor
vehicles-nearly 50,000 a year; this statistic is true for
both sexes (text table page 15). The mortality rate is
nearly three times as high for males as for females.


Table 8. Age-adjusted death rates per 100,000 population
for cancer of the respiratory system,' by sex and race,
selected years, 1950-77


White All other
Year Total
Male Female Male Female


1950 ....... 13 22 5 17 4
1960 ....... 19 35 5 36 6
1970 ....... 28 50 10 56 10
1975 ....... 33 55 14 67 13
1976 ....... 34 56 15 68 14
1977 ....... 34 56 16 71 16


1 Mainly cancer of the lung.
SOURCE: National Center for Health Statistics, National Center for
Health Services Research: Health, United States, 1979. DHEW Publication
No. (PHS) 80-1232, Hyattsville, Md., 1980; adapted from table 18.



Table 8A. Percent increase in age-adjusted death rates for
cancer of the respiratory system over three intervals,
by sex and race


Sex and race


1950-70


1970-77 1950-77


Total ...............
W hite male ..........
White female .......
All other male .......
All other female ......


SOURCE: National Center for Health Statistics, National Center for
Health Services Research: Health, United States, 1979. DHEW Publication
No. (PHS) 80-1232, Hyattsville, Md., 1980; adapted from table 18.

A large contribution to the rising mortality advantage
for females in the period 1930 to 1960 was the fact that
mortality for males from motor vehicle accidents was
rising even faster than that for women. The relative
advantage for females then decreased, and from 1970
to 1976 it stabilized.
More men than women are killed by accidents in the
home.

Recent trends in sex differentials in mortality. Ver-
brugge (4) notes that the sharply increasing female
mortality advantage has begun to change in the 1970s
in three ways:

1. The differential between men and women has
stabilized for cerebrovascular diseases, motor vehicle
accidents, and congenital anomalies.
2. The differential has narrowed for diseases of early
infancy, bronchitis, emphysema, asthma, homicide, and
peptic ulcer.
3. The differential has continued to increase, but at
a slower pace, for all other leading causes.


September-October 1980 21







Figure 8. Age-adjusted death rates for white females for leading sites of malignant neoplasms, United States, 1950-75


Rate per 100,000 Sites with increasing death rates Sites with decreasing death rates
population
Breast Lung Ovary, etc. Pancreas Leukemia
25



20







10


I I 0 60I I 0 '0 'I I I' I I I II
'60 '70 '50 '60 '70 '50 '60 '70 '50 '60 '70 '50


Brain, etc. Large intestine Cervix uteri Other parts of uterus Stomach
25
25 ---------- ----------- ----------- ---------- -----------------



20 ----------- ----------- ------------------------------







10








1950 '60 '70 '50 '60 '70 '50 '60 '70 '50 '60 '70 '50 '60 '70

Source. see figure 6.


Causes of Death of Concern to Women

In the preceding section, malignant neoplasms were
treated as a single category and represented the second
highest cause of death for women. The cancers consid-
ered subsequently, taken alone, are not necessarily
among the leading causes of death, but are of special
interest because they are gender-specific or, in the case
of lung cancer, because they have undergone recent
dramatic changes. Also included is a section on maternal


mortality, with comparisons of the risk of mortality
from various methods of fertility regulation.
Breast cancer. Breast cancer is the leading cause of
cancer death among women in the United States be-
tween the ages of 35 and 55, with a mortality rate of
23 per 100,000 population. The estimated number of
newly diagnosed breast cancer cases in this country in
1979 was 107,000, and about 35,000 women died of
cancers discovered and treated in earlier years. Overall,
1 in 13 American women will develop the disease at


22 Public Health Reports Supplement


Oi
1950


'60 '70







Figure 9. Age-adjusted death rates for all other females for leading sites of maligant neoplasms, United States, 1950-75


Rate per 100,000 Sites with increasing death rates Sites with decreasing death rates
population
Breast Large intestine Lung Pancreas Ovary, etc.



20 -- --------------------------
25



20 --






10






0 1 I i i1 I i i i i i 1 I I II I I i 1 i 1 i i i 1
1950 '60 '70 '50 '60 '70 '50 '60 '70 '50 '60 '70 '50 '60 '70


Leukemia Brain, etc. Cervix uteri Stomach Other parts of uterus
25


20






10






O1 I I I I I I I I I I
1950 '60 '70 '50 '60 '70 '50


; .: ,. ,:, -',




I '*t # 1 I

'70 '50 '60 '70


'60 '70


Source: see figure 6.


some time in her life, although certain populations of
women are at higher risk than others. Women who
have already had breast cancer are at greatest risk;
women whose mothers or sisters had it are also at high
risk, as are women who have never given birth. There
is some evidence that women who have diets high in
animal fat may also be at higher risk-for example,
women in Japan have a much lower risk of breast
cancer than American women, but the risk for Japa-
nese women in the United States approaches that for
white American women (5).


The incidence of breast cancer has been rising, par-
ticularly since the mid-1960s, and particularly among
women in their 20s and 30s. The mortality rate is
virtually unchanged since the 1930s, despite advances
in early detection and treatment (mortality rates have
declined for women under 50 and have risen for women
over 50). Breast cancer-like all cancers-is primarily
a disease associated with growing older: the longer a
woman lives, the greater her risk of dying from cancer,
although this risk is exceeded eventually by her risk of
death from heart disease.


September-October 1980 23






Events of the decade beginning in 1970 indicated that
mortality from breast cancer may have begun to decline.
The SEER (Surveillance, Epidemiology, and End Re-
sults) Report issued every 3 years by the National Can-
cer Institute, Department of Health and Human Serv-
ices (DHHS), has a "lag" of approximately 3 years in
its reflection of new detection and treatment modalities.
The SEER Report for 1973-76 did not show the effects
on mortality of the early detection programs of the
American Cancer Society, National Cancer Institute,
and other public and private agencies; nor is the impact
of mammography (breast X-rays) seen in those data.
Tumor size is related to survival; earlier detection
has resulted in fewer women with cancerous lymph
nodes (or glands) in the underarm areas. Since survival
is inversely related to the quantity of such invasion,
these findings provide the basis for expecting that mor-
tality rates may soon fall.
Detection and treatment alternatives have been sub-
ject to critical research and public scrutiny. Breast self-
examination is increasingly stressed in public education
efforts since it results in a large proportion of cancers
that are detected and amenable to treatment. In addi-
tion, thermography (which measures differential breast
surface temperature), ultrasound scanning, and mam-
mography have been utilized with varying degrees of
support in the medical research community. In 1977,
groups of experts convened by the National Cancer
Institute issued recommendations on mammography. A
Consensus Development Conference was then con-
vened by NCI to review the use of mammography as a
screening method to detect disease in women without
symptoms or suspicious findings. (Its value as a diag-
nostic method was not in question.) Among the many
conclusions and recommendations of the conference
were these:
No convincing justification for routine mammog-
raphy screening for women under 50 years of age has
been found. This does not imply, however, that physical
examination and breast self-examination are not im-
portant for women of any age.
Routine mammography for women 40-49 years of
age enrolled in Breast Cancer Detection Demonstration
Projects should be restricted to women who have a per-
sonal history of breast cancer or whose mothers or
sisters have a history of breast cancer.
Mammographic screening of women under 40 years
of age should be limited to those women having a per-
sonal history of breast cancer.
Because the potential benefits of thermography
have not been documented, it should be discontinued
as a routine part of the Breast Cancer Detection Dem-
onstration Projects, except for further research.


Table 9. Deaths per 100,000 females from uterine cancer,
all ages, by race: crude rates for 1950 and 1975;
age-adjusted (to 1950) rates for 1977


Cervix Endometrium Other 1 Total
Race and year specified specified unspecified uterine


Crude rates
White:
1950 ...... 10.2 1.4 8.2 19.8
1977 ...... 4.1 2.5 2.7 9.3
Nonwhite:
1950 ...... 18.0 1.0 13.7 32.7
1977 ...... 8.0 2.3 3.2 13.5

Age-adjusted rates 2
White:
1950 ............................... . 19.0
1975 ...................................... 7.5
Nonwhite:
1950 ......................... ........ ........ 40.6
1975 ......... .......... ............ 14.4

I Based on a Connecticut study of unspecified cases and British data,
it is believed that a large proportion are endometrial cancers.
2 Adjusted to the age distribution of the 1950 population (all races,
both sexes).
SOURCE: American Cancer Society, unpublished data, 1980.

Controversy still surrounds the choice of treatment
modalities. Surgery, even if it is minor, is always the
primary treatment. Surgery is needed at least to per-
form a biopsy to confirm the presence of a malignancy.
The extent of surgery thereafter, however, can vary
from tylectomy ("lumpectomy") to wedge resection, to
partial mastectomy (removal of the lump and part of
the breast), to modified radical mastectomy (removal
of the breast and lymph nodes only), to Halsted radical
(removal of the breast, nodes, and chest muscles).
Nonsurgical treatments include cytotoxic chemo-
therapy, radiation therapy of the breast, radiation im-
plants in the site where the removed tumor had been,
and hormonal therapy.
Another NIH Consensus Development Conference
in 1979 recommended that the modified radical mas-
tectomy be adopted as the standard operation for the
majority of patients with early symptoms of breast
cancer. Choice of treatment is influenced by the
woman's preference and the physician's recommenda-
tions in balancing risks and benefits; many of these
have not yet been statistically determined. Randomized
trials comparing survival probabilities according to
several treatment modalities (surgical, nonsurgical, and
combined) are now underway at the National Cancer
Institute, but definitive findings will not be available
for several years.
Consensus was also achieved at the same conference


24 Public Health Reports Supplement







Table 10. Incidence of uterine cancer: cases per 100,000
females of all ages, by race: 1947, 1969, and 1973-77

White Nonwhite
Years
Cervix Endometrium Cervix Endometrium

1947' ........ 38.4 22.4 74.6 15.6
19691 ........ 15.3 21.5 34.2 11.3
1973-772 ..... 11.3 28.4 26.0 13.2

1 Based on data from the National Cancer Institute's survey of 9 major
areas.
2 Based on data from the NCI's SEER program.
SOURCE: American Cancer Society, unpublished data.

that a two-step procedure should be done in most
cases-that is, when a biopsy reveals a malignancy, the
woman does not immediately undergo surgery, but
rather takes a few days to determine with her physi-
cian the next steps to take.
A number of private organizations were formed in
the 1960s and 1970s to assist women in coping with
physical and psychological problems associated with
breast cancer-coping with prostheses, exercises, self-
esteem and marital relations (baldness resulting from
chemotherapy, disfigurement from surgery or radia-
tion), reconstruction possibilities, and others. There are
also newly established regional cancer information
centers funded by NCI that offer assistance in locating
appropriate medical care, and in selecting the type of
treatment.

Cancer of the genital organs. Mortality from ovarian
cancer has been rising somewhat, while it has been
declining for uterine cancer-a 61 percent decline in
the 25 years from 1950 to 1975. The components of
uterine cancer-cervical, endometrial, and other sites-
however, contribute differently to this overall decline.
A major problem in interpreting the data is a large
residual category that is not specified as either cervical
or endometrial. Based on a special study in Connecti-
cut, however, and on data from Britain, there is reason
to believe that a large proportion of the unspecified
mortality (and incidence) refer to the endometrium.
Tables 9 and 10 illustrate sharp declines in cervical
cancer incidence and mortality among white and non-
white women, although incidence among the latter is
still more than twice as high as among the former.
Endometrial cancer incidence is much lower among
nonwhite women than among white women, and ap-
pears to have increased slightly for both groups in
recent years. Mortality from endometrial cancer does
not parallel incidence by race, as rates are nearly
equivalent for white and nonwhite women. The appar-
ent increase in mortality from endometrial cancer be-


comes much less certain if a significant proportion of
uterine cancer mortality from "other, unspecified" sites
is in fact endometrial cancer, as this category has de-
clined significantly for all races between 1970 and 1975.
Most sources attribute at least part of the remark-
able decline in cervical cancer mortality to the wide-
spread use of the Papanicolaou test for screening. By
1973, 75 percent of women over 17 had had at least
one such test. Family planning centers that receive
Federal funds must perform annual tests for all clients,
although the need for such frequent testing has been
recently called into question. Also, many women still
at risk are no longer family planning clients because
they have been sterilized or are post-menopausal, and
thus tend to drop away from this regular screening.
Accuracy of the test is another source of uncertainty
regarding its use. It has been suggested-though not
yet generally agreed-that a woman should have a
Papanicolaou test in each of 2 consecutive years starting
at age 20 or at onset of intercourse, then every 3 years
until 35, every 5 years from 35 to 60, then again every 3
years. Women of all ages should have the test more often
if they use oral contraceptives or estrogen therapy, have
had multiple sexual partners, or if they have pelvic
abnormalities. An NIH Consensus Development Con-
ference on Cervical Cancer Screening is planned for
1980.

Cancer of the respiratory system (mainly lung cancer).
Changing life styles account for many trends observ-
able in mortality. One of the most striking examples
is the rise in lung cancer in women that corresponds
with a sharp increase in smoking among women several
decades earlier. Tables 8 and 8a show an overall up-
ward trend in these deaths-an increase of 162 percent
in a quarter century-but the increase is dispropor-
tionately due to nonwhite males (318 percent increase)
and to females: 300 percent among nonwhite and 220
percent among white women. Although women of all
races are now equivalent in their death rates from lung
cancer (16 per 100,000), and still far below male
rates, nonwhite men (71 per 100,000) far exceed white
men (56 per 100,000) in their risk.
If the mortality risk from lung cancer continues to
rise at its present rate of increase, in a few years lung
cancer will surpass breast cancer as the leading cause
of cancer deaths in women.

Deaths from pregnancy, childbirth, and the puer-
perium and from fertility regulation. One of the most
dramatic improvements in mortality in this century
has been the drop in maternal mortality-from 608
deaths per 100,000 live births in 1915 to 9.9 in 1978,
as follows:


September-October 1980 25







Deaths per 100,000
Year live births
1915 .............. ...................... 608
1935 ................................... 582
1945 ................................... 207
1955 ................................... 47
1970 ................................... 21
1975 ................................... .11
1978 ................................... 9.9

SOURCE: National Center for Health Statistics: Vital sta-
tistics of the United States, published annually.

The improvement can be attributed both to improved
prenatal and postnatal care, a function of both
heightened maternal awareness, with improved self-
care during pregnancy, and to improvements in the
delivery of medical care-access to hospitals, better
technology, improved training for medical personnel.
That not all increased technology necessarily represents
"improvement," however, is attested to by current con-
troversies over obstetrical practices. (See also Chapter
5.)
Although the reduction in maternal mortality is an
accomplishment worthy of note, there remain dis-
parities between black and white women (fig. 10)-
maternal mortality is more than three times as high
for black as for white women, and it is declining more
slowly. Several nations (including Sweden, Denmark,
Norway, Netherlands, Switzerland, Canada) have ma-
ternal mortality rates even lower than those for the
United States.
Because of major decreases in both the number of
women who have children each year and in the ma-
ternal mortality rate among those women, fewer women
now die as a result of childbearing than die as a result


Figure 10. Maternal mortality rates, by race, 1976


Total



<20



20-24



25-29



30-34



35-39



40-44


12.3
9.0


!8.0
4.9
1 1.6

*9.0
7.1
17.2


7.9
&30.0

179
11.7


530.
30.0


mTotal
White
Im All other






Deaths per
100,000 births








12.1


111.4


65.6
63.0
-m u74.5


SOURCE: Daniels, P., and Weingarten, K.: A new look at the medical risks in late
childbearing. Women and Health 4: 5-36, spring 1979.
of using the various methods of fertility control (table
11). This is because in any year more than 15 million
women are exposed to the risks associated with use of
an intrauterine device or oral contraceptives or with
having an abortion or sterilization operation. Although


Table 11. Estimated number of deaths related to reproduction, by age groups, United States'


Associated with pregnancy and childbirth Associated with fertility regulation
Age group
(years) Uterine Ectopic Spon- Abortion
preg- preg- taneous Tradl- Ster/ll- Total
nancy 2 nancy 3 abortion 4 Total Pill s IUD 5 tional Legal 4 Illegal 4 zation 6


15-19 ........... 67 4 1 72 33 0 0 2 4 9 48
20-24 ........... 81 12 1 94 105 4 0 11 6 9 135
25-29 ........... 92 15 2 109 72 6 0 3 5 42 128
30-34 ........... 87 6 2 95 248 4 0 4 3 43 302
35-39 ........... 45 7 1 53 132 2 0 2 1 42 179
40-44 ........... 23 2 2 27 190 1 0 4 2 42 239

Total ....... 395 46 9 450 780 717 0 26 21 187 1,031


1 Estimates based on Vital statistics of the United States, 1973.
2 ICD 630, 632-639, 650-678.
3 ICD 631.
4 SOURCE: Center for Disease Control, Abortion Surveillance Branch.
5 Based on Kahn, H. S., and Tyler, C. W.: Mortality associated with use
of IUDs. JAMA 234: 57-59, Oct. 6, 1975; Monthly Vital Statistics Report,
Vol. 25, No. 7. Supplement, Oct. 4, 1976, Table 4; Inman, W. H. W., and
Vessey, M. P.: Investigation of deaths from pulmonary, coronary, and


cerebral thrombosis in women of child-bearing age. Br Med J 2: 193-199
(1968); Markush, R. E., and Seigel, D. G.: Oral contraceptives and mor-
tality trends from thromboembolism in the United States. Am J Public
Health 59: 418-434, March 1969.
6SOURCE: Ory, H. W., and Greenspan, J., Center for Disease Control,
Jan. 14, 1977, provisional estimates.
7 13 of these were using the Dalkon shield, an IUD no longer used In
the United States.



26 Public Health Reports Supplement








Table 12. Mortality associated with pregnancy and childbirth, legal abortion, use of oral contraceptives (by smoking status),
and IUDs, by age groups

Oral contraceptives 3
Age group Pregnancy and Legal IUDs 3
(years) childbirth I abortion 2IU
Nonsmokers 4 Smokers 4


15-19 .............. 11.1 1.2 1.2 1.4 0.8
20-24 .............. 10.0 1.2 1.2 1.4 0.8
25-29 .............. 12.5 1.4 1.2 1.4 1.0
30-34 .............. 24.9 1.4 1.8 10.4 1.0
35-39 .............. 44.0 1.8 3.9 12.8 1.4
40-44 .............. 71.4 1.8 6.6 58.4 1.4


1 Ratio per 100,000 live births (excluding abortion), United States, 4 Estimates by A. E. Jain.
1972-74. SOURCE: Tietze, C.: New estimates of mortality associated with fertility
2 Ratio per 100,000 first-trimester abortions, United States, 1972-74. control. Fam Plann Perspect 9: 74-76, March-April 1977, table 1.
3 Rate per 100,000 users per year.

Table 13. Relative risk' of death, by regimen of fertility regulation and age groups


Regimen of fertility regulation 15-19 20-24 25-29 30-34 35-39 40-44


No regulation .................. 28.0 30.5 24.7 46.3 69.3 113.0
Abortion only .................. 6.0 8.0 6.0 5.7 6.3 6.0
Pill only, nonsmokers ........... 6.5 7.0 4.7 7.3 15.0 35.5
Pill only, smokers ............... 7.5 8.0 5.3 36.0 44.7 294.5
IUD only ...................... 4.5 5.0 4.0 4.7 6.7 9.5
Traditional only ................ 5.5 8.0 6.7 12.0 16.7 21.0
Traditional plus abortion ....... 1.0 1.0 1.0 1.0 1.0 1.0


1 Relative risk is calculated assuming that the death rate for traditional SOURCE: Tietze, C.: New estimates of mortality associated with fer-
contraception backed up by abortion is 1 for each age group. utility control. Fam Plann Perspect 9: 74-76, March-April 1977, table 2.

Table 14. Age-adjusted death rates from diabetes, by selected years, sex, and race, 1968-77

Total White Nonwhite
Year
Male Female Male Female Male Female


1968 ................... 14.0 15.1 13.3 13.4 20.3 31.7
1969 ................... 13.7 14.9 12.9 13.2 20.4 31.1
1970 ................... 13.5 14.4 12.7 12.8 20.4 29.3
1971 ................... 13.2 14.0 12.4 12.3 20.4 30.2
1972 .................... 13.2 13.9 12.3 12.1 21.2 30.1
1973 ................... 12.9 13.3 12.0 11.6 21.1 28.6
1974 ................... 12.2 12.7 11.5 11.2 18.8 27.1
1975 ................... 11.4 11.6 10.7 10.2 17.9 24.6
1976 ................... 10.9 11.1 10.2 9.2 17.5 23.7
1977 ................... 10.5 10.3 9.8 9.0 16.3 22.0


SOURCE: Unpublished data of the National Center for Health Statistics.


the rate of death among women who conceive and
carry pregnancies to term is higher than the mortality
rate for women using these fertility regulation methods,
fewer women die from childbearing, since only about
3 million women bear children in any year (tables 12
and 13).
Although the risks associated with both childbearing
and with fertility control are low, they can be lowered


still further: maternal mortality can be reduced by
improved pre- and post-natal care and by further re-
duction in high-risk pregnancies through family plan-
ning. Mortality from fertility control can be reduced by
declines in smoking among women who use oral con-
traception, use of oral contraceptives with reduced
hormonal potency, elimination of illegal abortion, and
decreases in the proportion of late abortions performed.


September-October 1980 27







Table 15. Age-adjusted death rates per 100,000 population for homicide, by sex and race, selected years, 1950-77

Total White Nonwhite
Year
Both Male Female Both Male Female Both Male Female

1977 ............. 9.6 15.1 4.2 5.9 8.8 2.9 34.5 60.1 12.5
1976 .............. 9.5 15.1 4.1 5.5 8.6 2.7 36.4 63.3 13.2
1975 .............. 10.5 16.8 4.5 6.1 9.4 2.9 41.1 71.6 14.7
1970 .............. 9.1 14.9 3.7 4.7 7.3 2.2 41.3 72.8 13.7
1950 .............. 5.4 8.4 2.5 2.6 3.9 1.4 29.5 49.1 11.5

1 In 1977, the age groups in which the largest recent increases were SOURCE: National Center for Health Statistics, unpublished data.
recorded were as follows:
Age group
(years) Male Female
10-14 ......................... ............ 1.6 0.3
15-19 ...................................... 14.2 3.4
20-24 ...................................... 29.9 7.3

Table 16. Age-adjusted death rates per 100,000 population for suicide, by sex and race, selected years 1950-77

Total White Nonwhite
Year
Both Male Female Both Male Female Both Male Female

1950 .............. 11.0 17.3 4.9 11.6 18.1 5.3 4.8 7.8 1.8
1970 .............. 11.8 17.3 6.8 12.4 18.2 7.2 6.5 10.3 3.3
1975 .............. 12.6 19.0 6.9 13.3 19.8 7.3 7.5 12.1 3.5
1976 .............. 12.3 18.5 6.6 12.9 19.2 7.0 7.6 12.3 3.5
1977 .............. 12.9 19.7 6.8 13.6 20.6 7.2 7.8 12.6 3.7

SOURCE: National Center for Health Statistics, unpublished data.


Diabetes. Diabetes has been a major exception to the
mortality advantage for females but, in 1977, the rate
for males exceeded the rate for the females for the
first time (table 14). From 1920 to 1950, diabetes
mortality rates rose for both sexes, but more so for
females. From 1950 to the late 1960s, the rate for males
continued to rise, but the female rate fell, and the gap
began to narrow. From the late 1960s both rates fell,
until by 1977 the female disadvantage had been elimi-
nated (4).
Important racial differences exist, however. The
mortality rate for white males exceeded that for white
females in 1971: among nonwhites, mortality among
males is still exceeded by mortality among females. The
overall rate for diabetes mortality among both sexes
is twice as high for nonwhites as for whites (see also
section 4 on obesity, which is associated with diabetes).

Homicide and suicide. Men are three to four times as
likely to be victims of homicide as are women (table
15). Over the last decade, the greatest increases in
suicide deaths were in ages 20-24, followed by ages
15-19, but in all cases the rate for males greatly exceeds
the rate for females. Even at its peak (ages 45-54),
the suicide rate among females is only half that among
males. Homicide rates have risen since 1950 for both


races and sexes. Nonwhite males are most likely, and
white females least likely, to be victims of homicide.
Homicide is one of the few mortality areas where the
gap between females and males has narrowed during
the 1970s (4).
Male suicide rates are also three to four times those
of females (table 16). The black male and female
suicide rates have risen since 1940, but the white
female rate is unchanged and the white male rate-
still by far the highest-has declined somewhat. Black
females have by far the lowest suicide rate.

References
1. National Center for Health Statistics, National Center for
Health Services Research: Health United States 1978.
DHEW Publication No. (PHS) 79-1232, Hyattsville, Md.,
1979, p. 118.
2. Kannel, W. B.: Recent findings from the Framingham
study. Medical Times, April 1978.
3. Kannel, W. B., and Castilli, W. P.: The Framingham study
of coronary disease in women. Medical Times 100: 173-
184, May 1972.
4. Verbrugge, L.: Recent trends in sex mortality differentials
in the United States. Paper presented at the annual meet-
ing of the Population Association of America, April 1979,
Philadelphia.
5. Kushner, R.: Breast cancer: a personal history and inves-
tigative report. Harcourt Brace Javanovich, Inc., New
York, 1975.


28 Public Health Reports Supplement








Chapter 3. Morbidity


The preceding section showed that American women
live longer than men and that the gap in life expect-
ancy continues to widen. However, looking only at
longevity does not adequately reveal the underlying
picture of morbidity, which is more mixed than that
for mortality.
There are two major national sources of information
on health status. The Health Interview Survey (HIS),
a continuous source of data, is updated weekly; inter-
views are conducted in more than 40,000 households
annually. The Health and Nutrition Examination
Survey (HANES) includes physicians' examinations
as well as interviews of 20,000 persons; HANES-I
occurred in 1960-62, and HANES-II in 1970-74.
Morbidity data are inevitably not as precise as mor-
tality data. There are obvious biases in self-reporting-
whether it be of symptoms, well-being, or level of
restricted activity-as there are also biases in physician
diagnosis and employee disability days. In some in-
stances, it may be important to know how people feel;
in others, to know the actual prevalence or incidence
of a disease or condition; and in still others, to know
the burden the illness places on the health care system.
Interpretations of morbidity data are fraught with
difficulties, including the necessity to ask repeatedly


questions such as: Is an observed difference between
the sexes a function of women's concentration in lower
level jobs? Does the difference hold true regardless of
income status? Is it a biological difference, or can it
be attributed to women's greater sensitivity to symp-
toms? To their greater readiness to seek care for
themselves? Is a woman's time off from work related
not only to her own illness, but also to the need to
care for a child? To the nature of her job? To other
family commitments?
Data from HIS indicate that most Americans in 1977
perceived their own health to be good or excellent;
only 12 percent rated it fair or poor. Overall sex differ-
entials were minimal (table 17) : 11.4 percent of men
and 12.5 percent of women rated their health as fair
or poor. However, women not in the labor force were
more likely than women in the labor force to rate their
health as fair or poor (12.3 percent compared with
7.5 percent). Other indications from the Health and
Nutrition Examination Survey point to significant sex
differentials in "general well-being" (see Chapter 4.
Mental Health and Well-Being).
While women appear far less likely than men to be
unable to carry out their major activity, they are
slightly more apt to experience some limitation (table


September-October 1980 29







Table 17. Self-assessment of health and limitation of activity, by sex, 1977


Percent with limitations
Sex Percent with self-
and assessment of health Limited in amount Unable to
race as fair or poor Limited but not or kind of carry out
Total In major activity major activity major activity


Total ......... 11.9 13.0 3.0 6.5 3.4
Female ..... 12.5 12.0 3.0 7.6 1.3
Male ........ 11.4 14.1 3.0 5.2 5.8
White ....... 10.9 12.8 3.1 6.4 3.2
Black ....... 20.8 15.9 2.4 7.9 5.6


SOURCE: National Center for Health Statistics, National Center for
Health Services Research: Health, United States, 1979. DHEW Publication



17). Women are also more likely than men to report
restricted activity days (this includes bed-disability
days). Following are 1977 data by sex:


Restricted Bed Work
activity disability loss
Sex days per year days per year days
Both .............. 17.4 6.8
Female ............ 18.8 7.6 5.3
M ale .............. 15.9 5.9 4.6

SOURCE: National Center for Health Statistics, Health
Interview Survey.

Especially among persons 65 and older, women are
more likely than men to experience limitation in their
activities because of chronic conditions such as arthritis
and hypertension:


Percent of persons 65 and
older limited in activity


Condition
Arthritis and rheumatism .........
Heart condition .................
Hypertension without heart
involvement ..................
Visual impairment ..............
D iabetes .......................
Impairment of lower extremities
and hips .....................
Mental and nervous condition .....
Impairments of back and spine .....
Hearing impairments ............
Asthma .......................


Female
31.6
22.0


SOURCE: National Center for Health Statistics, National
Center for Health Services Research: Health United States
1978. DHEW Publication No. (PHS) 79-1232, Hyattsville,
Md., 1979, page 236.

Currently employed women experience, on the aver-
age, more work-loss days than do currently employed
men: 5.7 days compared with 4.9 in 1975 (fig. 11).


No. tPHS) 80-1232. Hyattsville, Md., 1980, table 23.


Because the major sex-age differences occur ap-
proximately during the childbearing ages (24-45) for
females, it is highly likely that a large proportion of
the higher rates for females can be attributed to
pregnancy and associated conditions (1).
In addition to differences attributable to pregnancy,
some differences may also be related to occupational
status. Service workers had the highest, and profes-
sional workers the lowest number of work-loss days.
(However, even within most occupational categories,
women up to age 44 have higher average work-loss
days than men.)
Additionally, 1977 data from the Health Interview
Survey indicate that:

Even when pregnancy and delivery are excluded,
females reported more acute conditions than males;
232 per 1,000 persons per year among females com-
Figure 11. Number of work-loss days per currently employed
person per year, by sex and age, United States, 1975


Days per person
per year
Female Male
a -


6-


4


2


0. I I I I I-
20 40 00 20
Age In years


4U tO


SOURCE: National Center for Health Statistics: Disability days, United States, 1975.
Vital and Health Statistics, Series 10, No. 118, DHEW Publication No. (PHS) 78-1546,
Hyattsville, Md., June 1978, page 4.


36 Public Health Reports Supplement







Table 18. Persons 18-74 years with serum cholesterol levels of 260 ml per 100 mg or more, by sex, 1960-62 and 1971-74,
in percentages


Percent of males with Percent of females with
levels of 260 mg per levels of 260 mg per
Age group 100 ml or more Percent 100 ml or more Percent
_change change
1960-62 1971-74 1960-62 1971-74


18-74 years, age-adjusted' 16.8

18-24 years .................. 3.9
25-34 years .................. 10.4
35-44 years .................. 20.2
45-54 years .................. 25.7
55-64 years .................. 23.5
65-74 years .................. 21.6


1 Age adjusted by the direct method to the 1971-74 civilian noninstitu-
tionalized population, using 6 age intervals.
SOURCE: National Center for Health Statistics: Total serum cholesterol
levels of adults 18-74 years, United States, 1971-74, by S. Abraham, C.
Johnson, and M. Carroll. Vital and Health Statistics, Series 11, No. 205.


pared with 204 among males; only in the case of
injuries do men have higher rates for the acute condi-
tions with the highest incidence; women report higher
incidence of respiratory conditions, infectious and
parasitic diseases, and digestive system conditions;
Females have a higher prevalence than males of
chronic diseases;
At older ages, women have more mobility limita-
tions than men.

Some of these differences may be due to the fact
that interview data rely on a sole household respondent
(usually female) who may report more conditions for
herself than for other household members; some may
be due to the fact that it is more socially acceptable
for women than men to acknowledge illness.

Data from the Health and Nutrition Examination
Survey indicate higher proportions of women than
men with symptoms of chronic diseases; elevated blood
glucose (diabetes); lower hematocrit (anemia) ; higher
serum cholesterol after age 55 (cardiovascular diseases,
table 18); and elevated blood pressure (hypertension,
table 19). Black women are especially likely to have
elevated serum cholesterol and elevated blood pressure.
"Definite hypertension" uncontrolled by diet or medi-
cation as determined by a single blood pressure meas-
urement of at least 160/95 Hg. is twice as prevalent
among black women as among white women (28.6
percent compared with 15.7 percent). Rates are higher
for black women than for black men after age 45
(50.9 percent compared with 36.8 percent), and higher
for white women than for white men after age 65 (42.3
percent compared with 35.3 percent) (2).
From various surveys and examinations, we learn


DHEW Publication No. (PHS) 78-1652. U.S. Government Printing Office,
Washington, D.C., April 1978
NOTE: Data are based on physical examination of a sample of the
civilian nonistitutionalized population.



that women report or are diagnosed as having higher
rates than men of hypertension and hypertensive heart
disease. Females report more hypertensive heart disease
and hypertension at all ages, but diagnostic examina-
tions find an excess among females only after age 50.
This may be an example of the greater likelihood of
women than men to perceive and/or report symptoms
or illness in an interview. Women also have higher
rates of definite heart disease, epilepsy (until age 45),
chronic sinusitis, disorders of the urinary system, frac-
tures (after age 45), visual impairments (after age
65), thyroid conditions, varicose veins, phlebitis, colitis,
gallstones, hepatitis, anorexia nervosa, and auto-immune
diseases such as lupus, multiple sclerosis, and rheuma-
toid arthritis.
Men, on the other hand, appear to suffer more than
women (based either on self-reported or diagnosed
rates of illness) from tuberculosis, gout, cerebrovascular
disease, arteriosclerosis, emphysema and asthma, peptic
ulcer, epilepsy (after age 45), coronary heart disease,
hernia, slipped disc, fractures (only until age 45),
visual impairments (until age 65), and hearing and
speech defects.
Clearly, it is not possible to say whether men or
women are "sicker." Females appear to suffer more
than males from acute conditions after early childhood
and from chronic diseases after age 45-50, but men
have higher rates of fatal diseases.
Verbrugge (3) summarizes a complicated picture in
this way:

1. Genetic factors:
Males are at a disadvantage because of (a) genetic
differences in disease vulnerability, (b) more diseases


September-October 1980 31


-12.5

-28.2
-21.2
-15.3
- 6.2
-14.0
- 3.2


-22.5

-34.8
-24.3
-25.6
-12.1
-29.0
-20.2







Table 19. Percent of persons 18-74 years with elevated blood pressure, by sex and age, 1960-62 and 1971-74


Sex and Total White Black
age group
(years) 1960-62 1971-74 1960-62 1971-74 1960-62 1971-74


Male
Total ................... 17.7 19.5 16.4 18.5 30.5 30.4
18-24 ................ 5.6 4.8 5.6 4.9 6.2 4.6
25-34 ................ 7.7 9.1 6.1 8.2 21.8 17.7
35-44 ................ 16.2 18.9 14.9 17.3 28.1 38.2
45-54 ................ 21.2 26.8 19.5 25.8 34.0 36.8
55-64 ................ 29.3 32.3 27.5 31.1 49.7 49.9
65-74 ................ 40.1 36.6 38.2 35.3 63.3 50.1
Female
Total ................... 17.4 16.8 15.9 15.2 30.9 30.9
18-24 ................ 1.6 1.6 1.5 1.4 2.3 2.9
25-34 ................ 3.1 4.4 2.3 3.7 8.8 10.2
35-44 ............... 10.8 12.3 8.4 10.1 29.9 28.3
45-54 ................ 21.1 21.9 18.5 18.9 43.8 50.9
55-64 ................ 33.9 34.0 32.3 31.7 50.5 54.5
65-74 ............... 56.6 43.9 55.1 42.3 79.0 58.8


SOURCE: National Center for Health Statistics: Blood pressure levels
of persons 6-74 years, United States, 1971-1974. Vital and Health Statis-


in males are linked to the sex chromosome, (c) they
are more susceptible to infections, and (d) they lack
the protective effect of estrogen.

Females are disadvantaged when (a) after meno-
pause, they lack estrogen protection and (b) during
pregnancy and reproductive years they are subject to
risks to which men are not exposed.

2. Acquired risks:
Males are disadvantaged because (a) some of their
jobs are more hazardous, (b) they engage more in
hazardous sports, (c) they are involved in more work-
related travel, (d) they drink and smoke more, and
(e) they may be more willing to take risks.

Females are disadvantaged because (a) they have
more contact with children's diseases and (b) they are
more concentrated in low-status, high-stress occupa-
tions.

3. Health care factors:
Males are (a) less apt to perceive symptoms, (b)
less apt to seek care, and (c) less likely to be screened
for other diseases when visiting a doctor for reproduc-
tive matters.

4. Reporting differences:
Higher levels of morbidity may be reported for
women than for men because (a) interviewers usually
are women; (b) respondents are usually women; and
(c) respondents are likely to report fewer symptoms
and conditions for family members than for themselves.


tics Series 11, No. 203, DHEW Publication No. (HRA) 78-1948, Hyattsville,
Md., September 1977.


In short, "longterm limitations and shortterm restric-
tions due to chronic problems are powerfully influenced
by factors besides physical status" (3). Differentials
reflect attitudes toward health and social roles, as well
as physical differences.


References
1. National Center for Health Statistics: Disability days,
United States 1975. Vital and Health Statistics Series 10,
No. 118. DHEW Publication No. (PHS) 78-1546, Hyatts-
ville, Md., 1978.

2. National Center for Health Statistics: Blood pressure levels
of persons 6-74 years, United States, 1971-1974. Vital
and Health Statistics Series 11, No. 203, DHEW Publica-
tion No. (HRA) 78-1948, Hyattsville, Md., September
1977.

3. Verbrugge, L.: Recent trends in sex mortality differentials
in the United States. Paper presented at the annual meet-
ing of the Population Association of America, April 1979,
Philadelphia.


32 Public Health Reports Supplement








Chapter 4. Other Health Concerns


In addition to the questions of morbidity that were
discussed in the preceding section, many other health
hazards and issues are of concern to women. These
include environmental health, substance abuse, violence,
and mental health (considered in this chapter) and
reproductive health (considered in chapter 5).
These hazards and conditions may affect men as well
as women; their inclusion is not meant to imply that
they are of concern only to women. They are discussed
in this report because they are issues which affect
women, in some instances to the same degree as men,
in other instances, to a different degree.

Environmental Health
In recent years a great deal of public attention has been
focused on environmental causes of illness. John Hig-
ginson (1), director of the World Health Organiza-
tion's International Agency for Research on Cancer,
notes that the term "environment" includes everything
that surrounds people-"the air you breathe, the cul-
ture you live in, the agricultural habits of your com-
munity, the social cultural habits, the social pressures,
the physical chemicals with which you come in contact,
the diet and so on." Higginson warns that increasing
attention to physical and chemical causes of cancer may
cause us to underestimate the cultural and behavioral
factors that influence susceptibility (2).
Some illnesses and conditions that are caused by,
partially caused by, or exacerbated by environmental
conditions are also related to culturally determined sex


roles-for example, occupational hazards and diseases
to which women are increasingly exposed as they enter
the labor force in even greater numbers; and stress
related diseases and conditions associated with two
full-time jobs (as women, in some instances, continue
to bear the main responsibility for home and child
care).

Occupational Health
Women's occupational health is not a new field. During
the first World War, Alice Hamilton identified chemi-
cal agents in the workplace which could affect the
developing embryo. During World War II, the U.S.
Army conducted a major investigation resulting in a
report by Anna Baetjer entitled "Women in Industry"
published in 1946. A 1975 report on "Occupational
Health Problems of Pregnant Women" by Vilma Hunt
for DHEW initiated a resurgence of interest in the area
(3). Conferences were held to gather information, such
as that sponsored by the Society for Occupational and
Environmental Health. The work and publications of
Jeanne Stellman (4) and Andrea Hricko (5) have
recently defined the scope of the problem.
In recent years, women's primary work setting has
shifted from unpaid labor in the home to paid labor
outside the home. The proportion of women working
outside the home has increased from 35 percent in
1954 to 51 percent in 1979. The Bureau of Labor
Statistics predicts a participation rate of 54 to 60
percent by 1990 (6).


September-October 1980 33







Women predominate in low-paying, nonunionized
occupations. Both of these factors may be associated
with increased health and safety hazards. Workers
may be afraid to complain about hazards because they
lack union protection. Hazards are often overlooked
in industries where women have been traditionally em-
ployed, such as health care, clerical work, textile
industry, and dry cleaning; workers in these industries
may be exposed to a variety of chemical, biological,
and physical hazards. Female workers may not be at
any greater risk than male workers, but the industries
listed as examples are female-intensive industries, and
thus the hazards discussed are of particular concern
to women.

In hospital and health care settings, where 75
percent of the workforce is female, persons are ex-
posed to biological hazards such as infectious diseases
from patient contact and laboratory work. Workers
are exposed to chemical hazards such as anesthetic
gases which can cause liver damage as well as affect
women's reproductive ability (7). Accidental injuries
from falls, slips, and lifting are also common among
women employed in hospitals (8). Dialysis technicians
and nursing staff in a Minnesota hospital were found
to have the highest incidence of viral hepatitis among
all hospital personnel (9).
SMore than 90 percent of all hairdressers and beau-
ticians are women. These workers are exposed to hair
sprays which have been shown to increase the risk of
lung disease (10). In the past, many aerosol sprays
contained vinyl chloride, a known liver carcinogen, and
the long-term effects of daily exposure to this agent are
unknown. Many hair dyes have been shown to be
mutagenic, and many mutagens are also carcinogens.
Eighty percent of all clerical workers are women.
Occupational hazards include injuries from poorly
designed equipment, excessive sitting, and exposure to
noise and chemicals from office machines (4).
Fifty-six percent of textile workers are women.
Many textile workers exposed to cotton dust have
developed byssinosis or brown lung disease. Exposure
to asbestos, which is still used in certain textile products,
may lead to the development of lung and other types of
cancer; carbon disulfide found in viscose rayon plants
may cause neurological effects (5,11).
Almost two-thirds of the workers in laundry and
dry cleaning establishments are women. Workers who
handle industrial laundry can be exposed to the same
chemicals found in the factory. Dry cleaning workers
are exposed to solvents, especially perchloroethylene,
which may cause neurological effects and liver damage


Figure 12. Eight year incidence of coronary heart disease
(CHD) by occupation, marital status, and children among work-
ing women aged 45-64 years


SNonclerical workers
SClerical workers


(Number of


Single


Ever-
no ch


Ever-married,
children


SOURCE: Haynes, S G., and Feinleib, M.; Women, work, and coronary heart dis-
ease: prospective findings from the Framingham Heart Study. Am J Public Health 70:
133-141 (1980).

(4). Perchloroethylene has been linked to cancer in
animal studies carried out under the aegis of the
National Cancer Institute.

Stress also appears to be a problem for some women
workers. Generalized stress response is a mechanism
for adjusting to the environment. Under usual or
slightly stressful conditions, stress will produce minor
bodily responses. When the amount of fluctuation is
large, stress can represent a serious threat to health.
A number of physical conditions appear to be related
to stress. Frequently, one or more of these factors are
found among women. Factors which can contribute to
stress are repetitive, paced work, limited opportunity,
low wages, and woman's dual responsibilities in the
home and workplace. From a ranking of 130 occupa-
tions by the Federal Government's National Institute
for Occupational Safety and Health (NIOSH), secre-
tary, laboratory technician, and waitress were all among
the jobs rated highest in stress (based on death records
and admission records to hospital and mental health
facilities in Tennessee, 1977).


34 Public Health Reports Supplement


rr-in u, 1 Aa







Recent data from the Framingham heart study indi-
cated that coronary heart disease rates for women
holding clerical jobs and who were married and had
children were almost twice as high as rates of non-
clerical workers or housewives (fig. 12). The most
significant factors found to be predictors of coronary
heart disease among clerical workers were suppressed
hostility, having a nonsupportive boss, and decreased
job mobility (12). These findings are consistent with
observations that women clerical workers may experi-
ence several forms of occupational stress, including a
lack of autonomy and control over the work environ-
ment, underutilization of skills, and lack of recognition
and accomplishments (4).
Estelle Ramey of the President's Advisory Committee
on Women stresses that it is not the entry into the work
force of large numbers of women that causes stress;
it is their dual role and nature of many of their low-
status jobs that produce stress. She also cites a prospec-
tive study by the Metropolitan Life Insurance Company
of "achieving women" (high status women who are
listed in Who's Who) who have not lost any of the
life expectancy advantage over men enjoyed by other
women. On the contrary, age-adjusted mortality data
show an increasing gap between women and men with
respect to deaths from cardiovascular diseases, which
belies the fast-growing assumption that women will
have to "pay" for their rise in the occupational world.
While gaining access to nontraditional blue collar
jobs, women have encountered discrimination con-
nected to workplace hazards. Hearings conducted in
1977-79 by the Occupational Safety and Health Ad-
ministration (OSHA) in regard to the lead industry
raised the question of whether to change safety con-
ditions in the workplace or to remove certain workers
from it.
Lead has long been recognized as an abortifacient
and a cause of infertility in women. It is not as well
known that lead's effects on reproduction can also occur
in men (5). Companies have responded to information
about lead's reproductive effects by excluding women
from work places with lead exposure. In some instances,
women have been allowed to keep their jobs only if
they can prove they can no longer bear children (5).
In 1979, in order to retain their jobs, five women em-
ployed at a West Virginia plant had to consent to be
sterilized.
An alternative to excluding certain workers (women
or men) from jobs involving exposure to hazardous
substances, or to requiring sterilization of either sex as
a prerequisite to retaining their jobs in such an environ-
ment, is the setting of safety standards that limit the
level of exposure and make the workplace safer. This


was done, for example, when it was learned that male
workers' fertility could be adversely affected by exposure
to Dibromochloropropane (DBCP).
NIOSH conducts studies on the reproductive effects
of occupational exposure to chemical and physical
agents. Currently, there are 18 ongoing epidemiological
and laboratory toxicological studies of the reproductive
effects on both males and females.
In 1978, OSHA initiated a program to provide
training and technical assistance to workers and em-
ployers on occupational safety and health through
grants to nonprofit organizations and educational in-
stitutions. OSHA's Institutional Competency Building
Program supports training to prevent occupational
safety and health hazards. Eleven of the 82 programs
have a special focus on industries where women pre-
dominate or include women workers as subjects for
their training sessions.
An additional initiative has been taken by the
Women's Bureau of the Department of Labor to spon-
sor, with OSHA, four conferences targeting female-
intensive industries with a high incidence of injuries
and illnesses (textile, cannery, health workers, and
meat wrappers and packers). The objective is to train
participants to recognize and eliminate safety and
health hazards.
Other conferences that have been sponsored by State
and labor federations, regional OSHA offices, and
"COSH" groups (coalitions of medical, union, and
legal staff, known as Committees on Occupational
Safety and Health) in at least eight States have cen-
tered on women's occupational health. Some unions,
such as the communication workers (predominantly
women), have begun to include occupational health as
part of their agenda at annual conferences.
As women's participation in the workforce has in-
creased, more attention has been given to this aspect
of women's health needs. Until recently, women's
occupational health concerns have been largely unex-
plored except as their working conditions affected preg-
nancy. Further investigations of chemical and physical
exposure are needed that will benefit both women and
men.

Safety in the Home

Although the fact that women have worked within
the home has been offered as a possible explanation for
their increased life expectancy, the home is not devoid
of exposure to toxic agents and other hazards. Indeed,
more men die from accidents in the home than do
women-thus being at home is surely no protection
from fatalities. Older women, many of them suffering


September-October 1980 35







from osteoporosis, and those with problems of alcohol
and drug abuse, have a higher risk of accidents and
falls, many of which occur in the home.
Many situations and substances in the home present
possible hazards-cleaning agents and pesticides, elec-
trical appliances, hairdryers containing asbestos, lad-
ders, and so forth. One example of how a Federal
agency can take steps to minimize a danger is in the
case of microwave ovens:

In 1971, the Food and Drug Administration established a
performance standard for microwave ovens to protect against
accidental exposure to high levels and severely limit exposure
to low levels of microwave radiation. The standard re-
quires two interlock systems and a monitoring device to assure
that microwave generation is stopped the moment the oven
door latch is released FDA continues to assess the margin
of safety that has been built into the standards (Food and
Drug Administration, unpublished document, 1980).

Another example of action by a Federal agency is
that taken by the U.S. Consumer Product Safety Com-
mission in assembling an exhaustive list of manufac-
turers, importers, and labelers of hairdryers (13),
noting which models contain asbestos and what com-
pany actions have been taken to repair or replace such
appliances.


Substance Abuse

Alcohol. Alcohol abuse has long been considered a
man's disease, and treatment efforts have remained
primarily directed toward a male population, although
estimates of the number of adult women with alcohol-
related problems range from 1.5 to 2.25 million (14).
Women's abuse of alcohol has often been denied by
friends and family or gone unrecognized by medical
personnel. Women with a drinking problem seeking
treatment have suffered the additional social stigma of
"female alcoholic."
Of the adult females who drink, 27 percent can be
classified as being "problem drinkers" or having poten-
tial problems with alcohol. Alcohol-related female
deaths may be as many as 50,000 a year, including
homicides, suicides, motor vehicle accidents, and other
types of accidents, cirrhosis of the liver, and alcoholic
psychosis (Reed, Patricia, National Institute on Alcohol
Abuse and Alcoholism; Alcohol, Drug Abuse, and
Mental Health Administration, unpublished data,
1980).
Early research findings on alcoholic men have been
assumed to apply to women as well; most research
specifically focused on alcoholic women has been limited
to the effects of alcoholism in pregnant women on their
offspring. Recent findings, however, indicate that the


reasons for alcohol problems differ: women are more
likely than men to begin drinking heavily with depres-
sion, sex role conflicts, and following specific crises such
as divorce or a child leaving home (14).

Possible effects on a child born to a woman who was
a heavy drinker during pregnancy include deficiencies
in weight and length, delay of intellectual development,
mental deficiency, poor coordination, heart valve de-
fects, brain cell abnormalities, and clustering of facial
abnormalities. Although the full-blown "fetal alcohol
syndrome" is unlikely to occur when alcohol consump-
tion is minimal, the evidence indicates that some poor
pregnancy outcomes remain likely (for example, low
birthweight, stillbirth, and deleterious effects affecting
the brain and central nervous system) (15).

In 1978, the Bureau of Alcohol, Tobacco and Fire-
arms in the U.S. Treasury Department, proposed that
current regulations be amended to require a warning
label on alcoholic beverage containers concerning the
consumption of alcohol by pregnant women and the
possibility of birth defects in their infants. After exten-
sive public discussion it was decided not to require
labeling; however, it was decided to initiate an inten-
sive public awareness program to last a year targeted
at pregnant women. The labeling issue may be recon-
sidered depending on the success of the campaign.

Historically, alcoholism treatment programs were ill-
equipped to handle women alcoholics. A national
survey of alcohol programs, as recent as 1976, by the
Association of Halfway House Alcoholism Programs,
found that of 161 programs, 9 percent were for women
only, 56 percent for men only and 30 percent were
co-ed, with 10 to 30 percent of beds reserved for
women (16). It is becoming more widely recognized
that treatment models need to be modified to meet
women's special needs such as providing child care and
all-women therapy groups.

The National Institute on Alcohol Abuse and Alco-
holism has funded experimental programs to work with
women alcoholics. One focuses on flight attendants as
an example of efforts to approach the problem through
an occupational setting. Other programs are attempting
to reach women who are not in the labor force.


Drugs: illicit and legal (prescription and nonprescrip-
tion). The United States shares with many other indus-
trialized nations the problem of drug abuse (17).
Recent evidence shows wide variations of drug use
among subgroups of the population: for example, males
are believed to be far in excess of females in their use
of illicit drugs, while females exceed males in use of


36 Public Health Reports Supplement







legal prescription drugs. Women accounted for 43
percent of drug-related deaths in 1977, and females
currently account for about 60 percent of emergency
room episodes for drug-related problems (18).
Illegal drugs. It is estimated that there are 250,000 her-
oin addicts in the United States; one-fourth are female.
Women have consistently constituted about one-fourth
of persons seeking treatment for illicit drug abuse; one-
fourth of the treatment center budget of the National
Institute on Drug Abuse (NIDA), a component of the
Alcohol, Drug Abuse, and Mental Health Administra-
tion, is for programs that involve women. Many demon-
stration projects on treatment alternatives that included
only males have recently given way to both-sex projects.
Research findings indicate several differences between
the heroin-addicted female and male in treatment.
Female addicts are more anxious, depressed, and have
lower self-esteem than males. In treatment, they see
themselves as worse people than men do, as discrimi-
nated against and looked down upon. In physical
examinations, many women are found to have gyne-
cological problems, yet they are rarely given full medi-
cal examinations. Pregnant addicts generally do not
obtain prenatal care until late in the pregnancy, if at
all (Forman, Jody, National Institute on Drug Abuse,
unpublished report, January 1980).


Legal drugs (prescription). Sixty-seven percent of pre-
scriptions for psychotropic drugs (for example, Valium
and Librium) are for women (President's Commis-
sion on Mental Health, 1978). According to 1977
data from the Drug Abuse Warning Network
(DAWN), sponsored by the Drug Enforcement Admin-
istration and NIDA, 32 million women had used tran-
quilizers at some time in their lives compared to 19
million men; 16 million women had used sedatives
compared to 12 million men; and 12 million women
had used stimulants compared to 5 million men (For-
man, Jody, National Institute on Drug Abuse, unpub-
lished report).
Differences in the manner and extent to which phy-
sicians prescribe for men and women may stem from
several causes: women's greater frequency of visits to
physicians; greater likelihood of physicians perceiving
women's illnesses as psychosomatic; women's more fre-
quent reporting of anxiety, stress, and diffuse symp-
toms (for which psychotropic drugs were developed) ;
and a focus on women in drug advertising and pro-
motion.
According to National Institute on Drug Abuse
surveys, abuse of psychoactive drugs in conjunction


with alcohol is common among women and leads to
cross-addiction problems. Surveys in 1973 and 1974 in
18 States found that among women using relaxants
and minor tranquilizers, two in five were heavy drinkers
as well (18). In 1978 the Food and Drug Administra-
tion determined that the use and abuse of minor
tranquilizers is a clear health hazard, particularly for
women.


Legal drugs (nonprescription). In studies of the use of
over-the-counter (OTC) nonprescription medication,
it has been found that women are more likely to use
them than men; for example, a household survey of
3,481 persons in Baltimore (19) found that 33 percent
of females and 20 percent of males had used some
form of OTC morbidity-related medicine (excluding
vitamins) in the 2 days preceding the interview. The
sex differential was mainly due to pain relievers; there
was little sex difference in the use of OTC medication
for coughs and colds, skin ointments, laxatives and
stomach remedies. On the other hand, Parry and col-
leagues in a national survey of 2,552 adults found that
the highest rates of use of OTC psychotherapeutic
drugs were among young males (17).

Verbrugge (20) summarizes the reasons put forward
to explain the differences between women and men in
their use of prescription and nonprescription medica-
tion: women may experience more actual morbidity
than men; they may tolerate pain and discomfort less
well; they have a keener perception of symptoms; they
are more willing to take medication; they make more
physician visits (and visits by either sex are likely to
lead to prescriptions); physicians are more likely to
prescribe for women than for men. Others, such as
Radloff (21), would add that "learned helplessness"
and social stereotypes of appropriate female sex role
behavior reinforce a sense of powerlessness, and the
need for females to seek assistance and comfort from
others and from external sources.


Smoking. The mortality section of this report contained
many positive data and noted a trend of continuing
improvement in women's health status and an advan-
tage over males in mortality rates for most diseases.
However, the most striking exception to this otherwise
encouraging picture is the enormous increase in lung
cancer deaths among women in the past 25 years. With
each successive generation, the smoking characteristics
of men and women have become increasingly similar.
The onset of widespread cigarette use among women
lagged behind that of men by 25 to 30 years. The
proportion of adult women smoking cigarettes did not


September-October 1980 37








Figure 13. Age-adjusted death rates from chronic obstructive
lung disease in women, rate per 100,000


10.7



9.1


Figure 14. Age-adjusted death rates from cancer in women


Rate per 100,000


22.1 22.6 22.2 22.8
Breast


22.9 22.7 23.4


6.0


Lung


I I I I I I I I
1950 '55 '60 '65 '70 '75 '77 '83
Projected


SOURCE: see figure 13.


1960


'75 '77


(Data for white women only)

SOURCE: Health consequences of smoking for women, a report of the Surgeon
General. Office on Smoking and Health, Public Health Service, Department of Health
and Human Services. Washington, D.C., 1980. In press.

exceed one-quarter until the beginning of World War
II. Among women, the average age of onset of regular
smoking declined with each successive birth cohort-
from 35 years of age for those born before 1900, to 16
years of age among those born between 1951 and 1960.
The average age of onset of regular smoking among
young women is now virtually identical to that of
young men. As men's and women's smoking charac-
teristics are becoming increasingly similar, their relative
risk for smoking-related diseases is becoming increas-
ingly similar as well.

The fallacy of women's immunity to these diseases
is now apparent. The mortality rate for women from
lung cancer stood fairly steady until the early 1960s,
when it was less than 5 deaths per 100,000 women. By
1968, as the findings of many large prospective studies
were published, women accounted for one-sixth of all
lung cancer deaths. These studies found that death
rates for women smokers were 2.5 to 5 times as great
as death rates from lung cancer among nonsmoking
women. By 1979, women accounted for one-fourth of
all lung cancer deaths. Within the next few years,
women cigarette smokers' risk of lung cancer death will


Figure 15. Percentage of adults who smoke


-Males
Females


1935 '55 '65 '70 '74'76'78'79


SOURCE: see figure 13.


38 Public Health Reports Supplement


Mai








Figure 16. Percentage of adolescents who smoke

12-14 Years 15-16 Years 17-18 Years
o
C
c'J ,-


Male
Female
im


'68 '74 '79


SOURCE: see figure 13.


approach 8 to 12 times that of women nonsmokers,
or the same relative risk as that of men (22).
Cigarette smoking is a major independent risk factor
for fatal and nonfatal heart attacks and sudden death
in both men and women. Smoking has a synergistic
effect with use of oral contraceptives-that is, the
combined effects are greater than the sum of the two
considered separately. The risk of heart attack in
women who take oral contraceptives is increased ten-
fold if they also smoke cigarettes.
There is abundant evidence that smoking during
pregnancy directly retards the rate of fetal growth and
increases the rate of spontaneous abortion, fetal death,
and neonatal death. There is growing evidence that
children of smoking mothers may have measurable
deficiencies in physical growth and intellectual and
emotional development that are independent of other
known risk factors (figs. 13-17 and reference 23).
Efforts to counter the abuse of cigarettes include the
following:

An Office on Smoking and Health within the
Public Health Service conducts both a public infor-


Figure 17. Risks per 1,000 from smoking during pregnancy


Spontaneous
abortions




Preterm births
less than
38 weeks



Full-term low birth
weights less than
2,500 grams



Perinatal deaths


Nonsmokers 1.0

S1.70



1.0

1.36


SOURCE: see figure 13.

mation and education program and a Technical Infor-
mation Service for scientific education.
The Department of Health and Human Services
(DHHS) supports many research activities that relate
to smoking through the National Institutes of Health
and other agencies.
Voluntary health agencies such as the American
Lung Association, American Heart Association, Ameri-
can Cancer Society, and various other community
groups are deeply involved in smoking cessation and
prevention efforts.

The combination of these efforts has resulted in a de-
cline in the percentage of adult women who smoke and
increasing attempts by adult women to quit. Unfor-
tunately, adolescent and young women are continuing
to take up smoking in large numbers, and women aged
17 to 24 who smoke currently outnumber their male
counterparts.

Cosmetics. Studies have shown that most chemicals in
cosmetics may penetrate the skin. Some have been
found to cause nervous disorders or cancer in animals.
The safety of many is unknown. Only a few manufac-
turers of cosmetics conduct premarket tests such as cul-
turing for bacteria. Many women are unaware that they
should not share or borrow cosmetics or that bacteria-
killing substances included in mascara, for example, will
be rendered ineffective if the product is diluted (a
common practice).


September-October 1980 39







Federal laws pertaining to the safety of cosmetics
are administered by the FDA; however, authority to
assure the safety of cosmetics on the market is limited.
The Food, Drug, and Cosmetic Act does not require
that cosmetics be proven safe and effective before they
are marketed. Color additives used in cosmetics, with
the exception of coal-tar hair dyes, must be tested for
safety and approval by FDA for use in food, drugs, and
cosmetics. Other cosmetic ingredients, however, are not
required to be approved for safety. Manufacturers may
use essentially any ingredient in a cosmetic or market
any cosmetic until it is determined that an ingredient
or product may be harmful to users. The act prohibits
the movement in interstate commerce of cosmetics that
are adulterated or mis-branded. The FDA also has
authority to regulate product labeling, including warn-
ings on the label. This was done, for example, when a
chemical used in hair dyes was determined to be carcin-
ogenic. Warnings are also appropriate when a product
is inadvertently or intentionally misused often enough to
constitute a hazard of widespread public concern.
Despite the significant limitations in the FDA's
authority to protect consumers from unsafe cosmetics,
several actions have been taken to increase protection
of the consumer. The cosmetic industry agreed to
voluntary registration of manufacturing establishments
and to report consumer complaints of adverse reactions
to the FDA. Although probably only a small proportion
of users report adverse effects to companies, these
complaints have provided important signals to the FDA
of unsafe products. The FDA has also expanded its
research studies on health hazards as part of its cosmetic
program activities. Inspections of manufacturing plants
enable the FDA to identify unsanitary conditions or
other situations that may present a hazard to consumers.

Rape
According to the FBI Uniform Crime Reports, there
were 67,131 reported forcible rapes in 1978-double
the number a decade earlier. Estimates of underre-
porting vary widely, but it is believed that rape is far
less likely to be reported than other crimes of violence,
primarily because the ordeal of medical examination,
police questioning, and trial (if the rapist is found and
indicted) is felt by many women to add to the trauma
of the rape itself. Marieskind notes that the apparent
lack of support for rape victims on the part of police,
hospitals, and families (24):

led to an area of focus in the Women's Health Movement-
the establishment of Rape Crisis Centers. Frequently operated
in conjunction with a women's health group or women's
center, rape crisis centers seek to provide peers who will ac-
company a woman through the various stages of reporting a


rape, offer counseling as needed, serve as an advocate during
a trial and remain in a supportive role for as long as
requested.
Many groups have worked in their communities to organize
educational sessions, self-defense classes, escort services, leg-
islative change to prevent a victim's sex life being put on
trial, pressure for better lighting particularly on college cam-
puses, improved security in college dormitories, as well as a
"third party reporting system" which enables victims who do
not want to prosecute to give information concerning the at-
tack to a third party who will relay it to the police. Some men
in Philadelphia have formed Men Organized Against Rape
(MOAR) to help partners and male family members of rape
victims.
In 1975, the National Coalition Against Sexual As-
sault was formed to enable greater communication and
coordination among grassroots rape crisis facilities
nationwide. Primary activities have been to share skills
and information, provide workshops and annual con-
ferences, and monitor relevant legislative initiatives.
Coordination on the State level among groups that
assist rape victims has facilitated reform of local in-
stitutions and efforts for fundraising. The Pennsylvania
Coalition Against Rape provides the following assist-
ance: educational programs to State organizations;
training for medical, law enforcement, legal, and social
service personnel; technical assistance to rape crisis
centers; compilation and analysis of statewide rape
crisis data; and materials and information on rape
issues. The unity among the 26 service facilities in
Pennsylvania made possible the proposal of a bill in
the spring of 1979 to establish a State Office on Crime
Victims, which is responsible for coordinating pro-
grams and obtaining reliable and permanent sources of
funds for domestic violence, rape crisis, and victim
witness programs. An accompanying bill proposed a fee
affixed to marriage licenses to provide program funding.
Several States have made important changes in their
laws regarding rape. In some, rape is no longer regarded
as a sexual crime, but as a crime of assault. Some States
now recognize rape by a husband against his wife. In
some States, laws regarding the permissible introduction
of evidence at a rape trial have been altered so that the
victim is not further victimized by the proceedings.
At the Federal level, legislation has been enacted
which funds research on rape. The National Center for
the Prevention and Control of Rape was authorized by
Congress and established within the National Institute
of Mental Health in April 1976. The Center functions
to support research and research demonstrations to
improve understanding of sexual assault, refine preven-
tion and treatment strategies, and implement public
policies and practices.
Future plans include continued research on the fol-
lowing: development and application of methods to


40 Public Health Reports Supplement







measure the nature and extent of sexual assault and
attitudes associated with sexual aggressiveness and
victimization; and development of programs to address
the unique needs of special populations such as the
elderly, the mentally and physically handicapped, male
victims of homosexual rape, and ethnic minorities. Re-
sources will be used to develop and evaluate models
of prevention and treatment that may be used by
service providers. Efforts have been started to encour-
age service outreach and collaboration among agencies.
Education and training of personnel and the public at
large will be given greater emphasis. The Center will
also encourage more attention to the formation and
impact of public policies concerning changes in State
sexual assault laws, in health insurance, and in man-
dated services. Efforts will continue to develop infor-
mation and training materials for practitioners, re-
searchers, and the public. Finally, the Center will seek
new approaches to the implementation of research
findings directed at improved prevention and treatment
(National Center for the Prevention and Control of
Rape. Annual report to Congress, 1977-1978).

Battered Women

The problem of battered women is found in all com-
munities, regardless of economic status, race, or other
factors. In the first large-scale systematic national sur-
vey, Straus (25) reported that 3.8 percent of couples
admitted to one or more attacks on the wife during a
12-month period (which would mean 1.8 million wives
were beaten by their husbands in a year). This statistic
should be taken as an underestimate due to the obvious
reluctance of many couples to report abuse in an inter-
view. Many others are believed to accept routine family
violence as a norm and thus under-report. How much
violence contributes to divorce is unknown because only
intact married couples were included in the sample.
In recent years, increased recognition of the problem
has been demonstrated by the growth of available serv-
ices, an increase in research, and the establishment of
offices within State and Federal agencies charged with
addressing the problems of domestic violence.
To address the needs of battered women, grassroots
organizations have established shelters and support serv-
ices on very limited budgets. Currently there are shelters
in most States, although State appropriations exist in
only 20 States. It is estimated that between 1977 and
1979, the number of shelters doubled from 150 to 300
(Center for Women Policy Studies). In rural areas,
communities have developed informal safe-home net-
works to address the need. Various support services can
be found through rape crisis centers, action councils,


departments of social services, and from private groups
without funds to establish shelters. Women have used
the local YWCA which has responded to the expressed
need by instituting programs for battered women. Legal
services are available for low-income women. Yet there
are still many women who have nowhere to turn, who
do not know of existing services, or who are afraid to
come forward and ask for help.

A major obstacle to the provision of services by local
groups has been the lack of funding sources and the
need to devote staff time and energy to the pursuit of
short-term funding from various sources. The two Fed-
eral agencies which are the primary sources of funding
are the Department of Health and Human Services and
in the Justice Department, the Law Enforcement As-
sistance Administration, which has spent $1 million on
demonstration projects. Other sources have been AC-
TION, which in 1978 established centers to serve bat-
tered women in 10 Federal regions; the Women's Policy
and Program Division in the Department of Housing
and Urban Development which is developing shelters
as demonstration projects; Community Services Admin-
istration which has established a pilot crisis center to
assist low-income battered women and children; and
Comprehensive Education and Training Act (CETA)
prime sponsors, funded by the Department of Labor,
who have funded over 100 programs to assist battered
women and their children (Perman, Florence, Division
of Federal Women's Program, DHHS, personal com-
munication, January 1980). The Office of Domestic
Violence was established in the Department of Health
and Human Services in 1979 to provide public informa-
tion, technical assistance training, and demonstration
activities.

In 1979, legislation was passed in the House of Rep-
resentatives that would address the issue. H.R. 2977, the
Domestic Violence Prevention and Services Act, would
authorize appropriations to stimulate efforts by State
and local public and private nonprofit agencies to pre-
vent domestic violence and assist victims and depend-
ents of victims. A total of $65 million would be appro-
priated over a 3-year period. The bill would also
establish a National Clearinghouse on Domestic Vio-
lence Programs to be linked with the National Center
on Child Abuse and Neglect. At this writing, the bill is
pending action in the Senate. Some States have passed
legislation, and the Center for Women Policy Studies
has compiled a chart (26) indicating provisions of State
legislation on domestic violence, including civil remedies
available to battered women, shelter services, data col-
lection, police training, and criminal proceedings.


September-October 1980 41









One of the problems facing service providers arises
because women usually can stay in temporary shelters
only for 30 days. Some women may require "second-
stage housing" where they can stay until they can
arrange for their own housing. There is also a need to
provide job training for some so that economic depend-
ence will not cause them to return to a dangerous home
situation.

Sexual Child Abuse
Victims of sexual child abuse, like those of rape and
spouse battering, are overwhelmingly female. Girls are
reported as having been abused at a much higher rate
than boys (estimates range from twice to 10 times as
often) and, although there have been cases where vic-
tims are as young as 4 months, the average age is be-
tween 11 and 14 years old (27).
The National Center on Child Abuse and Neglect
estimates that the current annual incidence of sexual
abuse in children is between 60,000 and 100,000 cases.
Reported cases are thought to represent a small per-
centage of the actual incidence because many parents
and families are reluctant to report such incidents to
authorities, and children often do not inform parents of
sexual abuse.
A large proportion of the abusers are parents or other
persons familiar to the child. Of 9,000 cases of sex
crimes against children reviewed by the American Hu-
mane Association in 1968, 75 percent were members of
the victim's household, relatives, neighbors, or acquain-
tances of the victims (28).

A number of factors influence how the child reacts
and assimilates the experience. These factors include
the child's age and developmental status, the relation-
ship of the abuser to the child, the amount of force
used, the degree of shame or guilt evoked in the child
for his or her participation and, more importantly, the
reaction of the child's parents and those professionals
who become involved in the case.

Treatment programs utilize family and group therapy
to help members of the family function in a more
healthy, child-oriented way. As more people have sought
help, greater attention has been given to treatment as
well as to legal and protective issues. In 1980, $4 mil-
lion has been allocated under the amended Child Abuse
Prevention and Treatment Act of 1974 specifically for
demonstration projects concerning child sexual abuse.


Mental Health and Well-Being
Sex differences in mental disorders. Sex differences in
the incidence of mental disorders are observed both in


Figure 18. Percentage of persons rating themselves on degree
of well-being, by sex, 1971-75


774


170


Female Male
Positive well-being


Female Male
Tension, stress, anxiety


SOURCE: Health and Nutrition Examination Survey, National Center for Health Sta-
tistics.


diagnostic data from mental health facilities and from
community-based surveys. The caution that must be
exercised when interpreting morbidity data is required
also when examining mental health indicators. The
same general types of sources of information are avail-
able for both mental and physical health-that is, rec-
ords of admissions to various types of facilities, and con-
ditions self-reported in community surveys. Each type
of aata has certain limitations (29) :


Admission rates to psychiatric services are a result not only of
the incidence of mental disorders, but a series of socioeconomic,
attitudinal, administrative, and related nosocomial factors .
[including] availability of mental hospital beds, availability and
uses of other community resources for diagnosis and treatment
of mental disorders, and personal and public attitudes that de-
termine to what facility an individual is referred for treatment.


Although it is commonly stated that there is an ex-
cess of female admissions to psychiatric in- and outpa-
tient facilities, if admissions to Veterans Administration
facilities are included in the count, the sex ratio reverses
-from 96 males per 100 females to 104 males per 100
females (29). Sex ratios of patients differ by all types
of facilities: females predominate in private mental hos-
pitals, community mental health centers, general hospi-
tal inpatient psychiatric services, and outpatient psychi-
atric services; males predominate in Veterans Adminis-


42 Public Health Reports Supplement







Figure 19.
"Have you




Extremely
bothered


Very
bothered


Quite
bothered


Bothered
some


Bothered
little


Not
bothered


SOURCEr.: Cannon, Mi. ., ana ieaiCK, R. vv.: Difnerential
utilization of psychiatric facilities by men and women, United
States 1970. Statistical Note 81. Survey and Reports Section,
Biometry Branch, Office of Program Planning and Evaluation,
Health Services and Mental Health Administration, June
1973, chart A.


When diagnostic data are analyzed by marital status,
unmarried women-single, divorced, and widowed-
show a lower incidence of mental illness than men in
the same categories; conversely, married women show a


Traditional and alternative treatment approaches.
Aside from sex-role related mental disorders, feminist
writers and researchers have been concerned in the past
decade with what they viewed as inadequate and, in
some situations inappropriate, therapeutic approaches.
They have criticized traditional treatment approaches
for overlooking the role that social factors play in psy-
chological development and for basing theories of female
psychology on the theories of growth and development


September-October 1980 43


Percentage of persons aged 25-74 responding to higher incidence of mental illness than married men
been bothered by nervousness or your 'nerves' in
the past month?" by sex (30).
Sex roles and mental disorders. In the past decade, sex
Male differences in the incidence and patterns of psychiatric
7 Female diagnosis have led to an examination of the relationship
07 between sex roles and mental health. The increasing
1.5 recognition that the ability to control one's life is essen-
tial to mental health has led to an examination of the
2.6 ways sex bias and sex-role stereotyping in society affect
.8 the mental health of women (31). The development of
strategies for intervention has included ways to alter un-
7 healthy child-rearing practices as well as intervention
57 approaches for adult women who must deal with the
9.9 stress of sex-role stereotyping and discrimination. Sex
bias and sex-role stereotyping of female clients by thera-
13 pists have also received attention. Researchers and prac-
18.3 titioners have begun to re-evaluate traditional treat-
ment approaches and to conclude that some of these
37.9 approaches are inadequate, if not inappropriate, to deal
with the full range of female clients' problems.
43.6 In an attempt to understand sex differentials in men-
tal disorders, researchers have examined the relation-
40 ship of career patterns and life events to those differen-
21.9 tials. Men, for example, become depressed at critical
junctures in their professional careers, whereas women
S o 0 in traditional roles show signs of depression soon after
0 10 20 30 40 50
Percent childbirth, when children leave home, or when they are
not employed outside the home (31). Weissman and
published figure based on data collected in Health and Nutrition Ex- Klerman (32) found higher rates of depression among
y I, 1971-75; Dr. Harold J. Dupuy, Psychological Adviser, National young married women with children and among older
hStatistics. married
women whose children have left home than among men
spitals (which serve males almost exclusively) in the same categories. Williams (33) observed that
te and county mental hospitals (29). women are more likely to have emotional problems than
ist frequently diagnosed conditions also vary men because their roles as wife and mother are often
confining, demanding, and boring. Although increasing
gnosis Percent employment opportunities have alleviated women's
stress related to boredom and isolation, new role ex-
disorders ........................... 16.3 pectations may create other kinds of stress for women
renia .............................. 15.8 (32). While women are more likely to be depressed and
e disorders ......................... 10.8 exhibit anxiety and phobias, men are more likely than

e disorders ......................... 24.1 women to resort to public displays of their emotional
renia .............................. 18.4 distress (for example, public alcoholism, violence against
t situational personality disorders ....... 9.1 other adults), again, possibly as a function of their sex
-, roles.


SOURCE: Un
amination Surve
Center for Health

tration hot
and in Sta
The mo
by sex:

Dia'
Males:
Alcohol
Schizophr
Depressiv
Females:
Depressiv
Schizoph:
Transient






Figure 20. Percentage of women aged 25-74 responding to
"Have you been bothered by nervousness or your 'nerves' in
the past month?" by work status


Figure 21. Percentage of persons aged 25-74 responding to
"Have you felt you were under any strain, stress, or pressure in
the past month?" by sex


0.8
Extremely *.8
bothered
4.2
I 3.6


Working
N Keeping house
=Something else
(Laid off, letiea
looking for work,
unable to work,
ill, student)


Very much
stress



Much stress



Some stress



Usual stress



Little stress


Very
bothered


Quite
bothered


Bothered
some


Bothered
ettle


Not
bothered


Male
Female


7.8
8.9

11.3

11.4


28.6


34.5


I I
10 20
Percent


SOURCE: see figure 19.


of men (34-37). Some have also criticized traditional
psychiatric treatment approaches, particularly medica-
tion and hospitalization, as oppressive to women and as
deterrents to female mental health (38). Others have
felt that traditional psychotherapy was geared more to
improving women's capacity to conform to traditional
social roles than to improving their mental health (39).
To overcome the inadequate range of interventions
with women, new theories of female psychology have
been developed which suggest some alternative ap-
proaches. The most notable of the new theories involves
the concept of androgyny which seeks to replace tradi-
tional personality assessment that assumes the traits of
masculinity and femininity lie on opposite ends of a
bi-polar continuum. Androgyny theorists argue that all
people integrate varying degrees of traits that have been
traditionally associated with either males or females
(40, 41). The resulting treatment approach is one
whose goal is to combine the positive characteristics of
both sexes.
Consciousness-raising groups were an innovation de-
veloped by women discontented with traditional ap-
proaches to therapy. Consciousness-raising was designed
to develop an awareness among women that others


share common feelings, frustrations, and constraints.
The small group structure of this approach lends itself
not only to assert oneself as an individual but also to
identify with others in the same situation (42).
Women have also found assertiveness training to
be useful. The benefits of this technique lie in its
ability to increase the individual's effectiveness in con-
trolling her environment. Assertiveness training be-
came particularly important to women who were social-
ized to be submissive, thus losing a sense of their own
individual identity and the ability to control their own
lives (43).
Regardless of the specific therapeutic techniques,
feminists have called for treatment approaches that in-
clude consideration of women's emotional problems
stemming from limits of their traditional sex roles in
society as well as their individual histories. Addition-
ally, feminists want therapists to be aware of the
ubiquitous, unconscious prejudices regarding gender-
appropriate behaviors. Although such caveats are com-
monly utilized in women's clinics throughout the coun-
try, it is still uncertain how fully these new approaches
have been incorporated into the mental health care
system (44).


44 Public Health Reports Supplement


I 9.2


16.8
S19.4
17.9


No stress
22.4

20 30 40 50
Percent
Percent


I
0 10


SOURCE: see figure 19.


30 40







Figure 22. Percentage of women 25-74 years responding to
"Have you felt you were under any strain, stress or pressure
during the past month?" by work status


Figure 23. Percentage of persons aged 25-74 responding to
"Have you been anxious, worried, or upset during the past
month?" by sex


2.0
Very much
stress 21
4.3


Much stress



Some stress



Usual stress



Little stress



No stress


10 20
Percent


Working
Keeping house
- Something else
(Laid off, retired,
looking for work,
unable io work,
ill. Sluer.nl


196
16.0
118.6


31.3
131.9


30 40


SOURCE: see figure 19.


Sex differences in "general well-being." Among the
various tests and measurements of general health that
were applied to the HANES sample of 6,900 adults in
1971-75 was a "psychological well-being" series (45):
The Index of General Psychological Well-Being is composed
of 18 items with a total of 128 response options. The response
option for each item that indicates the greatest distress is
scored zero. Some of the items and their response options also
permit representation of high-level positive well-being. The
total index scores range from 0 through 110, with low scores
Table 20. Mean total general well-being (GWB) scores,'
by education and income within sex

Total Total
Years of GWB score Family GWB score
completed ________ncome
education
education Male Female Male Female


0-4 ..... 77.3 67.3 Less than $7,000 86.6 73.8
5-7 ..... 81.4 76.7 $7,000 to $19,999 85.1 79.4
8-11 .... 84.0 75.5 $20,000+ 86.7 85.6
12-14 ... 85.7 80.1 .............. ... ...
15 or more 86.5 85.1 .............. ...

Total .. 85.1 79.3

1 See text for explanation of GWB scores.
SOURCE: Personal communication, January 1980, from Harold J. Dupuy,
Psychological Adviser, National Center for Health Statistics.


indicating distress and high scores indicating positive well-
being. Generally positive well-being is represented by scores
above 78 and marginal well-being by scores of 73 to 77. The
median score for the population estimates of adults, 25 to
74 years old, was between 83 and 84.

Overall, men described themselves as more likely than
women to experience positive well-being and less likely
to feel tension, stress, and anxiety (fig. 18). Black fe-
males reported not only the lowest level of positive
well-being, with 37 percent having positive scores, but
more than half reported moderate to severe levels of
stress. Almost a third of black females showed a level of

Table 20A. Mean general well-being scores adjusted for
differences in total GWB by educational level within sex
at three levels of family income

Adjusted GWB scores
Income
Male Female


Less than $7,000 .......... 85.5 81.5
$7,000-$19,999 ........... 86.4 85.3
$20,000 or more .......... 87.4 87.3

Total ................ 86.5 85.1


September-October 1980 45


Extremely
anxious


Male
Female


2.0

3.1

5.3


6.3
7.5


1


Very
anxious


Quite
anxious


Some
anxiety



Little
anxiety


Not
anxious


1.7

15.1


SOURCE: see figure 19.


39.7

4

38.6


10 20 30
Percent


40 50







Figure 24. Percentage of women, 25-74 years responding to
"Have you been anxious, worried, or upset in the past month?"
by work status


Figure 25. Mean general well-being scores, by marital status,
within sex group


anxious


Very .7
anxious .6
8.4

Quite 7.7
aI0xious W 7.4


Working
M Keeping house
m Something else
iLaid off. rebreo.
looKing tor work.
unable lo woar.,
ill, student)


Total females
Total males


Never married



Married


14.6

_18.4


Some
anxiety


Little
anxiety


Not
anxious


45.5
42.0
0


24.8


Separated



Divorced



Widowed


10 20 30 40 50
Percent


General psychological well-being
Severe~ Moderate Positive
distress- distress -^ well-being I
77.6
83.5


Females 78.3
81.4


78.8


-ig10


65.9
(77.7


73.2
077.7


S60 65 7 7 84.3

o 60 6 o5 70 7A 0 8i5'110


SOURCE: see figure 19.
distress comparable to that reported by three-fourths of
an independent sample of mental health patients.
Sex differences in response to several particular ques-
tions are shown in figs. 19 through 24. More men than
women are "not bothered" by nervousness. Among
women, those who are neither working nor keeping
house (but are laid off, retired, looking for work, unable
to work, ill, or a student) are far more likely to have
been "extremely bothered" by recent nervousness.
Women are more apt to feel themselves "under strain,
stress, or pressure."
However, when certain characteristics of respondents
are taken into account, an interesting picture emerges;
separated females have a notably lower overall general
well-being score than do men or women of all other
marital statuses (fig. 25). Within each marital status,
for both sexes, higher income is associated with higher
general well-being scores, and females have a higher
level of general psychological well-being when educa-
tion and family income are adjusted to the highest level
(tables 20, 20A). Dupuy (45) concluded that "the man-
ifest differences in general well-being between the sexes
reflect a true difference due to differential effects of


SOURCE: see figure 19.
sociocultural forces." That is, the scores are not due to
a greater female tendency to be aware of and report
distress or to a male tendency to "brave it out" and
hide distress. There is virtually no difference in general
well-being scores among upper-income highly educated
women.and men.

References
1. Cancer and environment. Higginson speaks out. Science
205: 1363, Sept. 28, 1979.
2. Berry, C., and Ferguson, T.: How to stay healthy in a
polluted world. Medical Self Care, No. 8, spring 1980.
3. Hunt, V.: Occupational problems of pregnant women,
1975. PB No. 254-032, National Technical Information
Service, Springfield, Va. 22161.
4. Stellman, J. M.: Women's work. Women's health. Pan-
theon Books, New York, 1977.
5. Hricko, A.: Social policy considerations of occupational
health standards: the example of lead and reproductive
effects. Prey Med 7: 394-407, September 1978.
6. Flaim, P., and Fullerton, H. N.: Labor force projections
to 1990. Three possible paths. Monthly Labor Rev 101:
25-35, December 1978.
7. American Society of Anesthesiologists: Occupational dis-
ease among operating room personnel. Anesthesiology 14:
321-340, October 1974.
8. Hricko, A., and Brunt, M.: Working for your life: a
woman's guide to job health hazards (Labor Occupa-


46 Public Health Reports Supplement







tional Health Program, Berkeley, Calif.). Health Research
Group, Washington, D.C., June 1976.
9. Osterholm, M., and Andrew, J.: Viral hepatitis in hos-
pital personnel in Minnesota. Minn Med 62: 683-689,
September 1979.
10. Palmer, A.: Respiratory disease prevalence in cosmetolo-
gists and its relationship to aerosol spray. Environ Res
19: 136-153 (1979).
11. Kilburn, K.: Women in the textile industry. In Proceed-
ings of the Conference on Women and the Workplace.
Society for Occupational and Environmental Health,
Washigton, D.C., 1977.
12. Haynes, S. G., and Feinleib, M.: Women, work and
coronary heart disease: prospective findings from the
Framingham heart study. Am J Public Health 70: 133-
141, February 1980.
13. U.S. Consumer Product Safety Commission: CPSC Bul-
letin, Washington, D.C., October 1979.
14. National Institute on Alcohol Abuse and Alcoholism:
Third special report to Congress on alcohol and health.
DHEW Publication No. (ADM) 78-569, Rockville, Md.,
June 1978.
15. Sergio, F.: Alcohol beverage consumption and out-
come of pregnancy (George Washington University,
Washington, D.C.), cited in Department of the Treasury
and Bureau of Alcohol, Tobacco, and Firearms: Fetal
alcohol syndrome. February 1979.
16. Sandmaier, M.: The invisible alcoholics-women and
alcohol abuse in America. McGraw-Hill Book Co., New
York, 1980.
17. Parry, H., et al.: National patterns of psychotherapeutic
drug use. Arch Gen Psychiatry 28: 769-783, June 1973.
18. Hecht, A.: Tranquilizers: use, abuse and dependency.
FDA Consumer 21-23, October 1978.
19. Bush, P. J., and Rabin, D. L.: Who's using nonprescribed
medicines? Med Care 14: 1014-1023, December 1976.
20. Verbrugge, L.: Recent trends in sex mortality differentials
in the United States. Paper presented at the annual meet-
ing of the Population Association of America, Phila-
delphia, April 1979.
21. Radloff, L. S.: Sex differences in depression: the effects
of occupation and marital status. Sex Roles 4: 3 (1975).
22. Office on Smoking and Health: Health consequences of
smoking for women. A report of the Surgeon General.
U.S. Public Health Service, 1980. In press.
23. Office on Smoking and Health: Smoking and health. A
report of the Surgeon General. DHEW Publication No.
(PHS) 79-50066. Rockville, Md., 1979.
24. Marieskind, H. I.: Women in the health care system:
patients, providers and programs. C. V. Mosby and Co.,
St. Louis, Mo., 1980.
25. Straus, M. A.: Wife beating. How common and why?
Victimology: an International Journal 2: 443-457
(1978).
26. Center for Women Policy Studies: Charts, RESPONSE to
violence and sexual abuse in the family. Vol. 2, No. 9,
August 1979.
27. Groth, A. N., and Birnbaum, H. J.: Adult sexual orien-
tation and attraction to underage persons. Arch Sex
Behav 7: 175-181 (1978).
28. DeFrancis, V.: Protecting the child victim of sex crimes
committed by adults. American Humane Association,
Denver, Colo., 1969.


29. Cannon, M. S., and Redick, R. W.: Differential utiliza-
tion of psychiatric facilities by men and women, United
States 1970. Statistical Note 81. Survey and Reports Sec-
tion, Biometry Branch, Office of Program Planning and
Evaluation, Health Services and Mental Health Admin-
istration, June 1973.
30. Cove, W. R., and Tudor, J. F.: Adult sex roles and
mental illness. Am J Sociol 78: 812-835 (1973).
31. Radloff, L. S., and Monroe, M. K.: Sex differences in
helplessness-with implications for depression. In Career
development and counseling of women, edited by L. S.
Hansen and R. S. Rapoza. Charles C Thomas, Spring-
field, Ill., 1978.
32. Weissman, M., and Klerman, G.: Sex differences and the
epidemiology of depression. Arch Gen Psychiatry 34: 98-
111 (1977).
33. Williams, J., editor: Psychology of women: selected read-
ings. W. W. Norton and Co., New York, 1979.
34. Menaker, E.: The therapy of women in the light of
psychoanalytic theory and the emergence of a new view.
In Women in therapy: new psychotherapies for a chang-
ing society, edited by V. Franks and V. Burtle, Brunner/
Mazel, Inc., New York, 1974, pp. 230-246.
35. Salzman, L.: Psychology of the female: a new look. In
Psychoanalysis of women: contributions to the new theory
and therapy, edited by J. B. Miller. Brunner/Mazel, Inc.,
New York, 1974, pp. 173-189.
36. Schafer, R.: Problems in Freud's psychology of women.
J Am Psychoanal Assoc 22: 459-485 (1974).
37. Shainess, N.: A psychiatrist's view: images of women-
past and present, overt and obscured. In Sisterhood is
powerful: an anthology of writings from the women's
liberation movement, edited by R. Morgan. Random
House, New York, 1970, pp. 230-245.
38. Walstedt, J. J.: The anatomy of oppression: a feminist
analysis of psychotherapy. Know, Inc., Pittsburgh, Pa.,
1971.
39. Keller, S.: The female role: constants and change. In
Women in therapy: new psychotherapies for a changing
society, edited by V. Franks and B. Burtel, Brunner/
Mazel, Inc., New York, 1974.
40. Bem, S. L., Martyna, W., and Watson, C.: Sex typing
and androgyny: further exploration of the expressive
domain. J Pers Soc Psychol 34: 1006-1023 (1976).
41. Spence, J. T., Helmreich, R., and Stepp, J.: The per-
sonal attributes questionnaire: a measure of sex-role
stereotypes and masculine-femininity. JASA Catalog of
Selected Documents in Psychology 4: 43 (1974).
42. Brodaky, A.: The psychologist's role in women's studies.
Paper presented at a meeting of the Southeastern Psycho-
logical Association, New Orleans, La., Apr. 6, 1973.
43. Jacubowski, P. A.: Assertive behavior and clinical prob-
lems in women. In Psychotherapy for women, edited by
E. Rawlings and D. Carter, Charles C Thomas, Spring-
field, Ill., 1977.
44. Naierman, N.: Sex discrimination in health and human
development. Final report of contract No. 100-18-0137.
Health Resources Administration, Hyattsville, Md., 1979.
45. Dupuy, H. J.: Self-representations of general psycho-
logical well-being of American adults. Paper presented at
the 106th annual meeting of the American Public Health
Association, Oct. 17, 1978, Los Angeles, Calif., and un-
published tables, January 1980.


September-October 1980 47








Chapter 5. Reproductive Health


Care must be taken when addressing the full scope of
women's health issues neither to overemphasize the im-
portance of reproduction to women's health nor to
neglect this important aspect of her life. The dramatic
changes in childbearing in the United States in this
century-its avoidance, postponement, spacing, and ter-
mination-affect every woman's life and interact with
other social and economic changes affecting women.
For example, current levels of female labor force par-
ticipation could not have been realized without ad-
vances in fertility regulation. For this reason, and be-
cause of the many sub-topics encompassed within the
subject "reproductive health," it has been separated
here from the "other health concerns" noted previously.
Despite recent reductions in maternal and infant
mortality, increased availability of new methods of fer-
tility control, and improved access to reproductive
health care for a broader segment of the population, the
levels of maternal and infant mortality and of unin-
tended childbearing are still too high. We need safer,
effective contraceptive methods for both males and fe-
males, and we must continue to reduce the discrepan-
cies which exist among economic and racial groups both
in access to quality care and in their consequent ability
to attain equal levels of reproductive health.

Menstruation
Young females often become aware of their reproduc-
tive function when they are prepared for (or enter un-
prepared into) puberty. Menstruation has frequently
been the source of cultural taboos and restrictions on
women's activities. Until recently, most research on
menstruation has focused on pathological or negative
features (1--3) and on antisocial behavior thought to
be associated with the menstrual period, for example,


Brandon's statement that "we can be reasonably confi-
dent that some of woman's contrariness is due less to
her nature than to the ebb and flow of hormones," as
cited by Matria and Mullen (4). In 1969 Dalton (5)
linked menstrual and premenstrual periods with in-
creased incidence of poor examination performance,
criminal behavior, psychiatric admissions, and other
antisocial or negative behavior. The methods which
generated these conclusions, however, have come under
critical review (6), and it should be noted that women's
elevated risks for suicide and motor accidents during or
prior to menstruation are still considerably below those
for men. More recently, Golub (7) found no significant
changes in anxiety, depression, or hostility throughout
the menstrual cycle. Other researchers have explored
the influence of cultural values on the personal experi-
ence of menstruation (4,8-10). The "curse of blood"
concept, found in most cultures, may result in a nega-
tive self-image which exacerbates physical symptoms
associated with hormonal changes. Thus, cultural fac-
tors may affect individual perceptions and experience
of menstrual pain and disability.
Recent medical research has identified an association
between dysmenorrhea and increased production of
prostaglandins, which has led to increased interest in
the use of anti-prostaglandin agents for the treatment
of dysmenorrhea.

Fertility Regulation and Birth Planning
The reduction in high-risk and unwanted pregnancies
and births that has occurred in recent decades is a de-
velopment of central importance to individual women,
their partners and families, and the community. Many
of its ramifications are immediately apparent, while
others may be important but less obvious, for example,


48 Public Health Reports Supplement





























the need to anticipate changes in the population in
order to plan appropriate social, educational, and health
services and facilities for major age groups.


Infertility and childlessness. Not all childless couples or
individuals are infertile, and not all infertile couples are
childless. The proportion of women at the end of the
childbearing age period (ages 50-54) who were child-
less dropped from 22 percent in 1960 to 10 percent in
1978 (11). The first of these cohorts passed through
their primary childbearing years (ages 20-29) from
1926 to 1939-the Depression. The latter cohort did
the same from 1944 to 1957-during the Baby Boom,
when voluntary childlessness was at a minimum. The
percent childless among women still in their prime
childbearing years (20-29) dropped from 28 percent in
1940-immediately post-Depression-to 13 percent in
1960, after the crest of the Baby Boom, and by 1979
had risen to 26 percent (personal communication of
January 1980 from Maurice Moore, U.S. Bureau of the
Census). Some of these childless women are postponing
their first birth, some are known to be sterile, and some
are voluntarily childless and intend to remain so. Of
those postponing, some may find they are unable to
conceive or bear.

In 1976 about 6.9 million couples, or 25 percent of
all married couples with the wife of childbearing age,
had fecundity impairments. Most of these couples al-
ready had one or more children and did not want more.
However, an estimated 2.7 million wanted to have
either their first or another child. About 848,00 of these
infertile or subfertile couples were childless, and 688,000
of them had only one child. In all, couples with im-
paired fecundity who wanted to have a baby or another


baby made up about 10 percent of the married couples
in which the wife was of childbearing age (12).
In 1978, a provision was included in Federal legisla-
tion that referral for infertility screening and treatment
be included among services offered by federally funded
family planning programs. The National Institutes of
Health's Center for Population Research has planned a
major new initiative for 1982 to explore causes of and
treatments for infertility.

In vitro fertilization. In 1979, the Ethics Advisory
Board (EAB) in a report to the Secretary of the De-
partment of Health, Education, and Welfare (DHEW)
concluded that it would be ethically acceptable for
DHEW to support in vitro fertilization research under
certain very limited conditions. The EAB explicitly re-
frained from recommending the level of financial sup-
port, if any, that DHEW (now the Department of
Health and Human Services-DHHS) should commit
to in vitro fertilization research, was extremely guarded
in its conclusions, and recommended that public funds
should be committed only after consideration of other
research projects that also address the issue of infertility,
such as diagnosis and treatment of gonococcal infections
leading to pelvic inflammatory disease and sterility. The
Board's report was published for public comment in the
summer of 1979. After the 13,000 comments which
were received are analyzed, the Secretary of DHHS
will decide whether or not to authorize the commit-
ment of departmental funds for such research.
Meanwhile, in Norfolk, Va., a privately funded
clinic opened in 1979. Its staff carries out in vitro fer-
tilization with transfer of the embryo to the woman's
uterus for continuation of the pregnancy to term. Al-
though several babies conceived in vitro have now been
born elsewhere, there has not yet been sufficient time


September-October 1980 49








Table 21. Percentage of currently married couples, wife 15-44 years, who are sterile, 1973 and 1976

Women
Both
Race Total Tubal Men, vasectomy sexes, all
Hysterectomy ligation other sterility

1973
Total ............... 23.8 6.8 7.8 8.1 1.1
White ............. 24.0 6.6 7.6 8.7 1.1
Black ............. 22.7 9.2 10.4 1.1 2.0
1976
Total ............... 30.2 7.0 10.2 10.3 2.7
White ............. 31.0 7.1 10.2 11.2 2.5
Black ............. 24.3 6.7 12.0 1.9 3.7

SOURCE: National Center for Health Statistics, National Survey of Family Growth.


for full-term deliveries to have occurred as a result of
research and treatment at the Norfolk clinic.

Contraception. By 1976, only 8 percent of ever-married
U.S. women who were at risk of unwanted conception
were not using contraception, according to data from
the National Survey of Family Growth. Of those using
a method-that is, sexually active and not pregnant,
post-partum, seeking to become pregnant, subfecund, or
sterile:

7.2 million were using oral contraceptives;
2.1 million were using IUDs;
2.1 million were using condoms;
1.0 million were using periodic abstinence (the "rhythm
method") ;
0.9 million were using foam;
0.8 million were using diaphragms;
0.8 million were using withdrawal (coitus interruptus);
and
0.6 million were using other methods (jelly, cream, sup-
positories, douche, and so forth).

An additional 5.7 million had been sterilized for contra-
ceptive purposes and 3.2 million more had had steriliz-
ing operations for reasons other than contraception. An
additional 590,000 tubal ligations were performed in
1976, and another 700,000 in 1977 (Greenspan, Joel,
Center for Disease Control, unpublished data, 1980).
In 1981, the National Survey of Family Growth will in-
clude never-married women as well, providing national
data on their contraceptive practices comparable to data
now available for ever-married women.
The NSFG documented peak use of nonsurgical
methods of contraception around 1973 and their de-
cline by 1976. Among black women, the decline between
1973 and 1976 in use of pills and IUDs (6.8 percent)
was twice that among white women (3 percent), but
black women increased their use of traditional (barrier
and other) methods by 6 percent (fig. 26).


In the 1960s and 1970s health activists and leaders
in and out of government stressed the need for increased
research to develop safer contraceptive methods, for
careful monitoring and testing of present methods, for
development of fertility regulation methods appropriate
to the diversity of women's life circumstances and pref-
erences, and for new and better methods of contracep-
tion for males. Both the private and the public arms of
family planning research, for example, the Alan Gutt-


Figure 26. Use of contraceptives by race among currently
married women, 15-44 years, 1973 and 1976, in percentages


1973


1976


Other
methods


IUD 6.6


b.1 6.1


SOURCE: National Center for Health Statistics: National Survey of Family Growth,
unpublished chart.


50 Public Health Reports Supplement








Table 22. Percentage of currently married couples, wife 15-44 years, who are sterile or using contraception, 1973 and 1976

Other temporary
Race Sterile 1 Pill IUD methods Total

1973
White ............... 24.0 25.1 6.6 22.3 78.0
Black ............... 22.7 26.3 7.6 11.4 68.0
1976
White ............... 31.0 22.5 6.1 20.4 80.0
Black ............... 24.3 22.0 6.1 17.3 69.7


SIncludes vasectomy, tubal ligations, hysterectomy, and all other
causes of sterility.

macher Institute, the Population Council, and the
NIH's Center for Population Research (CPR), initiated
and responded to public discussion of these concerns
(see subsequent section, Population Research). CPR's
research program for development and evaluation of
contraception is currently emphasizing research aimed
at altering hormonal contraception in ways that would
further reduce its health risks and side effects, at im-
proving vaginal contraceptives, developing new methods
of contraception for use by men, finding ways to in-
crease the effectiveness of natural family planning, and
further identifying health risks associated with fertility
regulation methods which are currently in use.
A number of research and service projects under-
taken by the Center for Population Research, Bureau
of Community Health Services, and the Food and Drug
Administration have also addressed these concerns. The
FDA, as a result of public pressure, now requires that
patient package inserts (PPIs) accompany oral con-
traceptives and IUDs; the regulation was issued in
response to public concern over contraceptive medica-
tion and devices; it first referred only to oral contra-
ceptives, then was broadened to all estrogens. In 1980,
the FDA will propose that it be extended to all pre-
scription drugs. PPIs are designed to inform users of the
purpose, proper use, and possible short- and long-term
side effects of the medication or device.
The use of cervical caps in the United States is cur-
rently an issue among some women, family planning
service providers, researchers, and the FDA. The
method is used in Europe and was used in the United
States in the 1950s and 1960s. Interest has recently been
revived, and a small number of feminist health centers
and private physicians have imported caps from Europe.
Hearings on cervical caps were held in 1979 by Senator
Kennedy's Health and Scientific Research Subcom-
mittee. Pursuant to the 1976 Medical Device Amend-
ments to the Food, Drug and Cosmetic Act, cervical
caps can be used in accordance with "investigational
device" regulations. The Center for Population Research


SOURCE: National Center for Health Statistics, National Survey of
Family Growth.

will provide funding for clinical trials to compare use-
effectiveness of cervical caps with that of diaphragms
and to stimulate research development to improve both
caps and diaphragms.

Sterilization and sterility. In 1970, approximately
200,000 U.S. women obtained tubal operations for steri-
lization; in 1977 approximately 700,000 did so. By 1976,
almost 10 percent of fertile-aged married women had
been surgically sterilized for the purpose of contracep-
tion, and another 10 percent were married to men who
had had vasectomies.
The prevalence of hysterectomy, shown in table 21,
increased slightly among white wives and decreased
among black wives between 1973 and 1976 (see also
subsequent section, Hysterectomy); tubal ligation in-
creased among both groups. The prevalence of vasec-
tomy increased among both black and white men; how-
ever, the procedure is considerably more common among
whites.
Prevalence rates (percent of those in a given popula-
tion who have ever been sterilized) must be distinguished
from annual incidence rates: in the early 1970s, black
women had higher yearly incidence rates of tubal
ligation than did white women; their rate leveled off
by 1975. The white rate increased over that time, so
that by mid-decade their incidence rates were equiv-
alent. In 1976 and 1977, the white rate is expected to
be even higher, bringing the prevalence rate among
whites closer to that among blacks (Greenspan, Joel,
Center for Disease Control, unpublished data, 1980).
Table 22 adds the percent of married couples who
were either sterile or practicing contraception: in
1976, of the 10.3 percent difference between white and
black couples sterile (because of sterilizing procedures
or other reasons) or using contraception (80.0 percent
versus 69.7 percent), 9.3 percent was due to the greater
prevalence of vasectomies among white men; white and
black couples were nearly identical in their contraceptive
practice and levels of sterility in all other respects.


September-October 1980 51








An issue of great concern is the coercion of some
poor and minority women (black, Native American,
Spanish-speaking) and the mentally incompetent to
undergo sterilizing operations. Also of concern, although
receiving less public attention, are the difficulties some
women encounter when attempting to obtain desired
sterilizations. Only recently has the obstetrician's "rule
of 120" been discarded. This "rule of thumb" dictated
that only women whose age and parity multiplied to
120 or more could be sterilized-that is, a woman who
was 20 years old and had 6 children, a woman 30 years
old with 4 children, or 40 years old with 3 children, and
so on. Lack of access to facilities, willing medical per-
sonnel, and ways to pay the bill continue to be barriers
to surgical sterilization for some women.
In 1978, the Department of Health, Education, and
Welfare, in response to litigation and public pressure
stemming primarily from allegations of coercion, issued
revised regulations regarding federally funded steriliza-
tions. These regulations prohibit federally funded sterili-
zation of persons who are under the age of 21, institu-
tionalized, or mentally incompetent. They require that
consent be given orally and in writing at least
30 days prior to the procedure (except in the case of
premature delivery or emergency abdominal surgery)
and that the woman receive adequate information on
alternative methods of family planning and on risks
and benefits of the proposed procedure. The consent
form is prescribed by the Department and states that
the procedure is considered to be irreversible. Consent
may not be obtained when the woman is undergoing
labor, seeking or obtaining an abortion, or under the
influence of alcohol or any other substance that may
affect her awareness.
Within the Department, the Office of Population
Affairs (OPA), Office of Human Development Services
(Title XX, Social Services), the Health Care Financing
Administration (Title XIX, Medicaid), and the Office
of the Inspector General all monitor compliance with
these regulations. In 1980, the OPA will conduct an
evaluation to ascertain if the regulations are having the
intended effect of preventing coercion while not cur-
tailing voluntary access.
Abortion. Beginning in 1967, 12 States partially liber-
alized their restrictive abortion laws to permit legal
abortion under a few circumstances. In 1970, three
States repealed their laws to, in effect, permit abortion
in the early weeks of pregnancy regardless of the reason.
In 1973, the U.S. Supreme Court ruled that abortion
in the first trimester was a matter of privacy between a
woman and her physician and that, in the second tri-
mester, the States may regulate the site and conditions
for performing abortions, but may not limit the reasons


justifying its performance. In the third trimester, States
may restrict abortions except when they are neces-
sary to preserve a woman's life or health. This decision
rendered invalid all State laws that were more restric-
tive.
Estimates from a variety of sources suggest that, prior
to liberalization, there may have been up to 1 million
illegal abortions a year. The number of legal abortions
rose with each step of liberalization, particularly after
1973. In 1978 there were 1.3 million legal abortions-
'3 to teenagers, /3 to women aged 20-24, and V/ to
women 25 or older.
Mortality from abortion declined dramatically over
this period, due both to improved care for women having
legal abortions and to the decreasing number of abor-
tions performed illegally under unsafe and unsanitary
conditions:


Deaths from


Deaths from legal


Year all abortions abortions only
1972 ................. 90 24
1973 ................. 56 25
1974 ................. 53 25
1975 ................. 47 29
1976 ................. 27 11
1977 ................. 133 15
1978 ................. 125 9

SIn 1978, 7 deaths were recorded from abortions illegally
induced by persons other than physicians, including self-
induced; about half of these occurred near the Mexican
border. In 1977, this number was 4.
SOURCE: Center for Disease Control; Abortion surveil-
lance, annual summary, 1977, issued September 1979; and for
1978, unpublished data from C. Tyler, of the Center, January
1980.

Abortion procedures also changed over this period,
accompanied by declining rates of complications and
morbidity. Suction curettage (vacuum aspiration) has
largely replaced sharp curettage (D&C) for first tri-
mester abortions, and increasing numbers of physicians
and hospitals are now willing to perform dilation and
evacuation (D&E) in pregnancies of 13-15 weeks
duration. This procedure carries lower complication
rates than either saline or prostaglandin instillation for
early second trimester abortions. The organization of
many free-standing specialty abortion clinics, where
patients are treated on an outpatient basis, has been
credited with making possible a lower rate of complica-
tions in early abortions than in other countries.
Another important development is the continued de-
cline in the proportion of abortions performed in the
second trimester of pregnancy (when the procedure is
more dangerous)-down from 17.9 percent in 1972 to
8.6 percent in 1977 (13). Some of this decline is at-
tributed to easier access to early abortions and wider
public awareness of the greater safety of early pro-


52 Public Health Reports Supplement







Figure 27. Unintended births among ever married women,
15-44 years, 1973 and 1976 in percentages


62
Wanted
births


14
Unwanted
births


24
Mistimed
births









65
Wanted
births


11
Unwanted
births


24
Mistimed
births


SOURCE: National Center for Health Statistics: National Survey of Family Growth,
unpublished chart.

cedures. However, the proportion of abortions performed
in the second trimester may increase, as techniques for
detection of fetal deformities are improved and used
more widely.
In June 1977, the U.S. Supreme Court ruled that
States are not required to pay for nontherapeuticc"
abortions for poor women. Soon thereafter the U.S.
Congress passed the "Hyde amendment," which pro-
hibited the use of Federal (DHEW) funds to pay for
abortions except where the pregnant woman's life
would be endangered by continuation of the pregnancy,
in cases of rape and incest, and where two physicians
certified that continuation of the pregnancy would
result in severe and long-lasting damage to her physical
health. (The last of these exceptions was not included


1973


in the 1979 renewal of the amendment.) Although 10
States and the District of Columbia continued to use
State funds to pay for abortions for Medicaid-eligible
women (two of these States pay only for "medically
necessary" procedures), other States limited their abor-
tion funding and introduced conditions similar to or
even more restrictive than the Federal Hyde amend-
ment. As a result of these changes there was a 99 per-
cent decrease in publicly funded abortions. While
preliminary 1978 data do not indicate a substantial
reduction in the total number of abortions, the funding
cutoff may be resulting in an increase in the proportion
of late procedures. The Center for Disease Control, in
a special study, has found an average delay of 2 weeks
in obtaining abortions by welfare-dependent women in
areas where funds were restricted (14).
In January 1980, a Federal district court judge ruled
that the Hyde amendment is unconstitutional. Although
the ruling will be appealed, some Federal funding of
abortions has resumed. The issue of abortion-both its
legality and the question of public funding-continues
to be a divisive and important issue in American poli-
tics and health care.

Unintended (unwanted and mistimed) births. Surveys
that explore the degree of "unwantedness" of American
births found a dramatic decline of more than a third
between the first and second halves of the 1960s, but a
leveling off in the 1970s. In 1976, 11 percent of births
were unwanted and an additional 24 percent were mis-
timed, according to NSFG data (fig. 27).
In the survey, "unwantedness" is determined on the
basis of a series of questions about planning status, use
of contraception at the time of conception, and whether
or not the woman had wanted any more children at
the time of conception. Respondents are not asked
whether or not they currently (at the time of the
interview) want a particular child.
White women have long had lower fertility rates
than women of other races. Although fertility rates for
both white and black American women have declined
since 1957, the decline has been steeper among white
women. The persistent racial differential is not due
to a desire for larger families on the part of black
women, but to the greater frequency of unintended
births and a longer exposure to the risk of pregnancy
resulting from onset of sexual activity at an earlier age.
The "aspiration gap" (between desired and achieved
levels of fertility) has narrowed over the years for
both whites and blacks, but is still wider for blacks: 24
percent of births to married black women in the 3
years preceding the 1976 NSFG were "unwanted" with
an additional 25 percent mistimed.


September-October 1980 53








It is important to point out that the notion of
"wanted" births occurs within a complex social frame-
work. Women and their partners formulate notions of
appropriate levels of fertility based not only on their
own personal desires but also on response to pressures
for larger or smaller family size that occur within social
contexts, both macro (national) and micro (their im-
mediate community, colleagues, or family). In recent
years, pressures for relatively large families have
given way to greater acceptability of and pressures
toward relatively smaller families. Effective contracep-
tive practice, in such a changing climate, must increase
just to keep up with declining levels of wanted fertility,
while unwanted fertility appears not to decline at all.

Premarital conceptions and out-of-wedlock births. Of
the 6.7 million American women younger than 25 years
who married for the first time between 1972 and 1976,
9 percent were already mothers before they married
and 14 percent were at least 6 weeks pregnant on the
day of their wedding. Almost one in four began mar-
riage pregnant or with an existing child. The younger
a woman is at the time of her first marriage, the more
likely it is that she is already pregnant. Almost one in
three 14- to 17-year-old brides is pregnant, compared
to 6 percent of women who first marry at ages 20-24.
The proportion of brides who were already pregnant
increased in this country between 1952 and 1971, after
which it stabilized and decreased for the 18- to 21-year-
old group. There is evidence that marriage under these
circumstances predisposes couples to economic disad-
vantage throughout a considerable period of their lives,
and these couples are more likely than others to divorce
(15).
More than half a million babies were born to unmar-
ried American women in 1977, an increase of more
than 10 percent over 1976. The rate of out-of-wedlock
births per 1,000 unmarried 15- to 44-year-old women,
which decreased in the early 1970s, rose again between
1976 and 1977:


Year
1940
1950
1960
1970
1973
1974
1975
1976
1977


Rate
7.1
14.1
21.6
26.4
24.5
24.1
24.8
24.7
26.0


Ratio o
37.9
39.8
52.7
106.9
129.8
132.3
142.5
147.8
155.0


'Number of out-of-wedlock births per 1,000 unmarried
females 15-44 years old.
SNumber of out-of-wedlock births per 1,000 live births.
SOURCE: Vital statistics of the United States, Vol. II.
Natality. National Center for Health Statistics, 1978 (for
1940-1975); and 1976-77 data from Monthly Vital Statistics,
National Center for Health Statistics, 1979.


Figure 28. Trends in Federal support for population research,
by major research area, fiscal years 1970-78

Percent of
total funds
Reproductive processes
Social and behavioral sciences
1ir1111.,1 Contraceptive development
SContraceptive evaluation
50



40




30



on


0 1 I i I I
1970 '71 '72 '73 '74 '75 '76 '77
Fiscal year


SOURCE: Center for Population Research, National Institute of Child Health and
Human Development, National Institutes of Health. Inventory of Population Research,
1979.

This increase may reflect an increase in wanted rather
than unwanted births to unmarried women, some of
whom live in relatively stable relationships with the
fathers of their children. More than half of the births
to unmarried women are births to teenagers.
Family planning services. For many years in the United
States, family planning services were provided only by
private physicians to middle- and upper-income women.
The pioneering efforts of Margaret Sanger and her fol-
lowers in the Birth Control League, the forerunner of
the Planned Parenthood Federation of America, resulted
in the formation of privately funded clinics for lower-
income women. Eventually, hospitals and health de-
partments began to provide family planning services. In
1967 amendments to the Federal Economic Opportu-
nity Act (the "War on Poverty") included funding for
family planning services, and amendments to the Social
Security Act required welfare agencies to provide fam-
ily planning services. In 1970, the Family Planning
Services and Population Research Act, Title X of the
Public Health Service Act, was adopted. Title X pro-


54 Public Health Reports Supplement


.............................
.............................
.............................
.............................
.............................
.............................
.............................







Figure 29. Population research areas with more than $1 million support by Federal agencies in fiscal years 1977 and 1978'


Reproductive endocrinology

Male fertility

Female fertility

Fertilization
Zygote transport, preimplantation
development and implantation
Human infertility


Drug synthesis and testing
Drug delivery and oral formulations


Contraceptives

Sterilization



Animal reproductive behavior



Fertility
.Migration and
population distribution
Population policy

Mortality

Population change


FY 1977
FY 1977


.a*3tN ~


I I I I I I I
0 2 4 6 8 10 12
Millions of dollars


SCenter for Population Research grants are excluded
SThe two research areas within contraceptive development are new in FY 1978.
SOURCE: National Institute for Child Health and Human Development,
National Institutes of Health.
videos funding for project grants and contracts for fam-
ily planning services, training, service delivery improve-
ment research, information/education, and population
research. (See also Population Research, the following
section.)
In 1970, only 414,000 women were served by the
federally funded Title X family planning program; by
1975 this number had risen to 3.2 million and by 1978
to approximately 4 million. In addition 3 million poor
and near-poor women received family planning care
from private physicians, some of whom were paid by
Federal (Medicaid) funds.
The Alan Guttmacher Institute estimates that 10.1
million American women are "in need" of subsidized
family planning services, including 5.0 million poor and
near-poor adult women and 5.1 million teenagers, who
are considered to be without discretionary income, re-
gardless of family income.


Reproductive
FY 1978 processes


Contraceptive
development2


Contraceptive
evaluation


Animal behavior
and ecology



Social and
behavioral
sciences


S 1I I I I
14 16 18 20 22


Population research. The same Title X of the Public
Health Service Act which provides Federal funds for
family planning services also provides money for family
planning and population research, both in biomedical
and in social and behavioral sciences. In addition to
Title X funds for the Center for Population Research,
other Federal agencies, mainly the Agency for Interna-
tional Development, also support family planning and
population research. Trends in Federal support for such
research are shown in figs. 28 and 29.
Public expenditures for research on male fertility
(within reproductive processes) grew from $2.7 million
in 1973 to $7 million in 1978. Although this category
for research on male reproduction exceeded expendi-
tures for female fertility research in 1978, over the 6-
year period, more money was spent studying females
(table 23). In the private sector, male fertility research
has recently dropped tenfold, from $392,000 in 1973 to
$42,000 in 1977.


September-October 1980 55


. ,, .. .








Table 23. Federal support for population research, selected topics, 1973-78, in millions of dollars

Basic research: reproductive processes Applied research
Fiscal year
Male Female Contraceptive Contraceptive
fertility fertility development evaluation Total


1973 .............. $ 2.7 $ 3.3 $ 6.1 $10.2 $ 16.3
1974 .............. 4.0 3.2 6.4 7.5 13.9
1975 .............. 2.9 3.5 9.4 7.3 16.7
1976 .............. 4.8 4.2 11.2 7.0 18.2
Transition quarter' .. 0.4 0.4 1.1 1.6 2.7
1977 .............. 5.0 4.7 14.7 11.8 26.5
1978 .............. 7.0 5.7 13.8 8.9 22.7

1973-78 ........ $19.8 $25.0 $62.7 $54.3 $117.0


1 In 1976, the fiscal year changed from July-June to October-
September.
SOURCE: Personal communication from Rolf Versteeg, Center for

Public sector funding of research in contraceptive de-
velopment and evaluation decreased in 1979, largely
because of reductions in this category from the Agency
for International Development in the Department of
State.

Pregnancy and Pregnancy Outcome
Nearly all American women experience one or
more pregnancies at some time in their lives. Even
among those with fecundity impairments or presumed
sterility, many have either already had a pregnancy
(resulting either in fetal loss or live birth), or will go

Table 24. Median number of prenatal visits in metropolitan
and nonmetropolitan areas, by educational attainment of the
mother and race of the child, 1975


Years of school
completed by mother
and race of child


All races ......
0-8 ........
9-11 ...
12 .. ......
13-15 ......
16 or more ..
W hite ........
0-8 ........
9-11 ...
12 .........
13-15 ......
16 or more ..
Black .........
0-8 ........
9-11 ...
12 .........
13-15 .......
16 or more ..


SOURCE: Ahearn, Mary, U.S.
paper on child health, 1979.


Number of visits by residence


All areas Metropolitan Nonmetropolitan


Department of Agriculture, unpublished


Population Research, National Institute of Child Health and Human Devel-
opment, National Institutes of Health, January 1980.


on to have a pregnancy in the future. Even among the
voluntarily childless, some have experienced or will ex-
perience unwanted pregnancies which they terminate.

Prenatal care. The percent of American women who
obtain early prenatal care has been rising. In 1977, 74
percent obtained prenatal care in the first trimester (77
percent of white women and 59 percent of black women
(11)); 1.4 percent got no prenatal care at all (1.1 per-
cent of white and 2.8 percent of black mothers). This
percentage varies with age: 5.8 percent of girls under
15 had no prenatal care. Often those most at risk of
poor pregnancy outcome-poor, young, rural, and mi-
nority women-were least likely to obtain early prenatal
care.
The median number of prenatal visits in 1975 varied
from a low of 8.3 for nonmetropolitan black women
with low educational levels to a high of 11.9 for metro-
politan white women with 16 or more years of education.
Overall the average number of visits is 10.8. (Ahearn,
Mary, U.S. Department of Agriculture, unpublished
paper on child health, 1979, and table 24.)

Technology used during the prenatal period-ultra-
sound, X-rays, and amniocentesis. Diagnostic ultra-
sound is used extensively during pregnancy. Approxi-
mately half the pregnant women in the United States
receive ultrasound scans to determine the age of the
fetus and the location of the placenta. Additionally,
ultrasound is increasingly used on a routine basis to
monitor the status of the unborn baby during labor.
While benefits of these obstetrical procedures are recog-
nized, there is concern that the potential for biological
risks is not yet understood. The benefit-to-risk ratio,
particularly of routine ultrasound, has been called into
question. In February 1979, the Food and Drug Admin-
istration issued a notice that it is considering the devel-


56 Public Health Reports Supplement







opment of performance standards for diagnostic ultra-
sound equipment and recommended that ultrasound be
used only for obtaining essential diagnostic information.
The American Institute of Ultrasound in Medicine and
the National Electrical Manufacturers Association are
collaborating on voluntary safety standards for ultra-
sound equipment. The FDA is conducting the support-
ing research to determine the possibility of adverse bio-
logical effects.
Physical agents which are known to be hazardous are
of extra concern during pregnancy because of the spe-
cial sensitivity of the human embryo and fetus. One
such agent is ionizing radiation, which is received by
the fetus during abdominal X-rays of pregnant women.
In 1970, the latest year for which data are available,
approximately 298,000 infants born in the United States
had been exposed to diagnostic X-rays in utero. It is
estimated that a typical abdominal X-ray examination
doubles a child's risk of developing cancer in the first
15 years of life from about 1 in 1,000 to about 2 in
1,000. Prenatal irradiation has also been associated with
increased risks for some diseases and genetic changes
that are difficult to detect and quantify. It has been
estimated that as many as 30 percent of all medical
X-rays in the United States may be medically unneces-
sary. Efforts to reduce the number of unproductive
X-ray examinations, particularly of pregnant women,
include the following:

In November 1979, the FDA recommended to the
medical community that pregnancy status be ascer-
tained prior to ordering abdominal X-rays of women
of reproductive age.
The FDA, the American College of Obstetricians
and Gynecologists, and the American College of Radi-

Table 25. Percentage of live births attended by physicians
in hospitals, by race, selected years, 1940-77

Year All races White All other

1940 .......... 55.8 59.9 26.7
1945 .......... 78.8 84.3 40.2
1950 .......... 88.0 92.8 57.9
1955 .......... 94.4 97.5 76.0
1960 .......... 96.6 98.8 85.0
1965 .......... 97.4 98.9 89.8
1970 .......... 99.4 99.7 97.8
1971 .......... 99.1 99.5 97.1
1972 .......... 99.2 99.5 98.0
1973 .......... 99.3 99.5 98.3
1974 .......... 99.2 99.3 98.4
1975 .......... 98.7 98.9 98.1
1976 .......... 98.6 98.7 98.3
1977 .......... 98.5 98.6 98.3


SOURCE: National Center for Health
United States, published annually.


Statistics: Vital statistics of the


ology are developing a joint policy statement advising
against the routine use of X-ray pelvimetry to deter-
mine the need for Cesarean section and encouraging the
use of other modalities that do not involve exposure to
radiation.
The FDA has promoted widespread use of a poster
and pamphlet in the waiting rooms of health facilities
where X-rays are ordered or conducted to advise
women who are or might be pregnant to alert the
physician to that possibility before undergoing X-ray
examinations.

Amniocentesis is a procedure to diagnose in utero
certain hereditary diseases and congenital defects. It is
especially appropriate for pregnant women over age
35 or for those who have already borne a child with a
chromosomal abnormality. Although approximately
150,000-200,000 such women give birth each year, only
about 15,000 amniocentesis procedures were done in
1979. Insurance coverage for amniocentesis varies, but
is most often limited to cases where the procedure is
needed to diagnose a problem related to the health
of the woman rather than of the fetus.
The Task Force on Predictors of Hereditary Disease
or Congenital Defects concluded that amniocentesis is
highly accurate and entails little risk to fetus or mother,
but that it should be preceded by pulse-echo sonography
to provide a guide for the proper insertion of the needle
(16).

Obstetrical practices. Several issues regarding child-
birth are of current interest and involve a good deal
of controversy: the place of birth, the attendant, the
social and emotional environment in which women give
birth, and preparation for the process of labor and
delivery.
The 1979 edition of Health United States reported
(11) :

The increase in the technological management of normal
pregnancy has come into conflict with a movement toward
natural childbirth and a general increase in concern about the
adverse effects of technology, some of which may not be ap-
parent for many years. In addition, techniques for antenatal
diagnosis (i.e., techniques used to diagnose problems of the
fetus prior to birth), raise serious ethical, legal, and economic
issues.
In 1940 only 56 percent of births occurred in hospi-
tals. Access to hospital care has greatly improved, so
that by 1970, 99.4 percent of births occurred in hospi-
tals. The wide racial disparity in use of hospitals for
childbirth which existed in 1950, when 60 percent of
white births but only 27 percent of other births occurred
in hospitals, has disappeared; 98.5 percent of white
and 98.3 percent of other births occurred in hospitals
in 1977 (table 25).


September-October 1980 57








Alternate places for delivery-homes and "birthing
centers"-have in recent years been supported by a
small but growing number of advocates and clients.
Birthing centers are places where labor, delivery, and
post-partum care can be provided in a home-like setting
with the father present, either in a hospital or a com-
munity-based facility: care is provided by professional
birth attendants (physicians or nurse-midwives).
During the 1970s there has been increasing interest in
involving fathers in the childbirth experience, in order
to make it a family event. Advocates of "family-
centered" births (with the husband present) maintain
that it contributes to partner "bonding," while its critics
believe the husband's emotional needs may direct at-
tention away from necessary medical procedures. In
1980, Marieskind (17) noted that "several studies and
the American Medical Association's Committee on Ma-
ternal and Child Care have noted the benefits and the
lack of detriment to outcome from family centered
births. The AMA's Committee on Maternal and Child
Care calls for a review of all hospital procedures and
professional practices with an eye to 'encouraging the
hospitals to assess their policies in support of the bond-
ing principle.' The AMA, however, despite its Com-
mittee's support for family-centered births in hospitals,
disapproves of all nonhospital sites for delivery.

Figure 30. Selected gynecological and obstetrical procedures
per 100,000, 1970-77


1,000


Dilation and
curettage
(diagnostic)


Hysterectomies .,new,.
600 A* ..... ...&ls-





400


Cesarean-
sections
200,


OI I I I I
1970 '71 '72 '73 '74 '75 '76 '77


SOURCE: Hospital Discharge Survey, National Center for Health Statistics.


While many middle-class women and couples can
afford to pay for childbirth educational classes, and
some hospitals incorporate them into their prenatal
care, they are unavailable to many poor women whose
clinics do not provide classes and whose insurance does
not cover them.
Increasing numbers of parents now seek to avoid a
medicated, instrument-assisted delivery. Preparation of
both husband and wife for labor and delivery results
in a reduced need for medication.
There is also a small but growing number of parents
who choose to have their birth attended by certified
nurse-midwives (CNMs) rather than by physicians-
whether in hospitals, birthing centers, or homes. (See
also Chapter 6, Women as Health Care Providers.)
Some observers are concerned that electronic fetal
monitoring (EFM) may pose problems for either or
both the mother and the infant. For example, there is
a temporal, and to a limited extent a causal, relation-
ship between increasing use of electronic fetal monitor-
ing and a steep rise in delivery by Cesarean section (fig.
30). In 1968, 5 percent of deliveries were performed
by Cesarean section; by 1977, this operation had risen
to 12.8 percent.


Cesarean sections

Number Percent
172,000 5.0
na na
na na
194,000 5.6
227,000 6.7
246,000 7.5
286,000 8.7
328,000 9.9
378,000 11.4
455,000 12.8


SOURCE: Marieskind, H. I.: An evaluation of Cesarean
section in the United States. Final report submitted to the
Office of the Assistant Secretary for Planning and Evaluation/
Health, Department of Health, Education, and Welfare, 1979,
table 1.

Marieskind (18) identified 11 factors which con-
tribute to this increase, as indicated by the literature,
data, and physicians she surveyed. Among the reasons
most frequently suggested by physicians were the threat
of malpractice lawsuits when vaginal delivery results
in a nonperfect infant, the policy of routine repeat
C-section for those who have had a prior delivery in
this manner, inadequate physician training for man-
agement of complications of labor and delivery by tra-
ditional methods, a belief that increased use of
C-section is responsible for declines in perinatal mor-
tality, a widening of the acceptable indications for
performance of abdominal delivery, changes in age and


58 Public Health Reports Supplement


.........................
.........................
.........................
.........................
.........................
.........................
.........................
.........................
.........................
.........................


uVW







Figure 31. Percent of ever-married women, 15-44
breast fed their first child, by duration of feeding
birth, and race, 1973


Breast fed E
3 months or more
.,.13 ;! 39


Breast fea
any durati


Year of
first birth
All years

1971-73
1966-70
1961-65
1956-60
1951-55
1950
and before


All years

1971 73
1966-70
1961-65
1956-60
1951-55
1950
and before

All years

1971-73
1966-70
1961-65
1956-60
1951 55
1950
and before


'Includes white, black, and other races
SOURCE. Hirschman, C., and Hendershot, G.: Trends in breaks
American mothers. National Center for Health Statistics, Vital and
Series 23. No. 3, November 1979.
parity of the childbearing population, and
incentives.
Research findings to date are not consisted
meeting a survival benefit to infants from
of electronic monitoring or from a high Ce:
tion rate. However, it is clear that maternal
and mortality from delivery by C-section gre
those from vaginal delivery. Banta and Th;
reported that C-section mortality is three tir
mortality from vaginal delivery. The Nati
tutes of Health plan a Consensus Develop:
ference on Childbirth by Cesarean Section
ber 1980.
Lactation. Both the 1973 National Survey
Growth and the 1965 National Fertility S


7 I29



13i 1 43







8 30




18. .E1~5
120 39if~3





13i1

17'~~k~~d i 43
ZQZ4


36~~hi


September-October 1980 59


I years, who showed a dramatic decline in breastfeeding in the
, year of first
year of first United States in recent generations, from 72 percent
who breastfed their first child in 1931-35 to 29 percent
d in 1971-73 (fig. 31). The decline occurred in most
on socioeconomic and cultural groups but was greater
All women' among poor women, black women, and women with
relatively little education. In the early 1970s, the
decline leveled off, and a recent report by the Ameri-
can Academy of Pediatrics noted an increase from 24.7
percent of infants breastfed in hospitals in 1971 to
46.6 percent in 1978-an increase that occurred at all
ages and among all income and educational levels (21).
In 1973, social differentials remained: Protestants
60 are most likely and Jews least likely to breastfeed; black
women were more likely until the 1950s, and are now
less likely than whites to breastfeed. Hispanic women
White of both races were intermediate between blacks and
whites in all periods. Farm women were more likely
and are now less likely than nonfarm women to breast-
feed. In the 1950s, women with the least and the most
education were most likely to breastfeed; in recent years
breastfeeding is more common among those with the
most education.
3
Pregnancy outcome. Although pregnancy outcome is
generally thought of in the immediate medical sense of
Black maternal, perinatal, and infant mortality and morbid-
ity, "outcome" can also encompass longer-term medical
consequences such as decreased longevity due to
pregnancy-caused chronic illness (for example, chronic
hypertensive disease following toxemia of pregnancy),
as well as psychosocial and sociomedical consequences,
such as postpartum depression, marital dysfunction,
59 family disruption, and divorce.
*iA: 73 Maternal mortality in the United States has declined
dramatically in this century, from more than 600
maternal deaths per 100,000 live births in the early
'feeding Samng 1900s, to only 9.9 deaths per 100,000 live births in 1978
Health Statistics,
(fig. 10 and text table page 26). However, the United
economic States' rate is higher than in some other industrialized
nations, and discrepancies exist between racial and
nt in docu- socioeconomic subgroups. The rate among blacks is
routine use three times that among whites.
sarean sec- There are approximately 4 million pregnancies a
Smorbidity year: over a million are intentionally terminated; 1
atly exceed percent result in fetal deaths; approximately 1 percent
acker (19) of infants die within the first month of life; about 7

nes that of percent are low birthweight, and nearly 5 percent have
onal Insti- a significant congenital malformation, birth defect, or
ment Con- genetic disorder (22).
in Septem- Infant mortality in the United States fell from 20
per 1,000 live births in 1970 to 14.1 in 1977-almost a
of Family 30 percent drop in 7 years. Yet despite impressive de-
Itudy (20) dines in infant mortality (fig. 32), the United States







Figure 32. Infant mortality rate per 1,000 live births



16



15



8 14
0



Z 13



12




1975 '76 '77 '78 '79


SOURCE: National Center for Health Statistics. Births, marriages, divorces and
deaths for 1979. Monthly Vital Statistics Report, Vol 28, No 12, DHEW Publication
No. (PHS) 80-1120, Mar. 14, 1980; Natonal Center for Health Statistics: Annual sum-
mary for the United States, 1978. Monthly Vital Statistics Report, Vol. 27, No. 13, DHEW
Publication No. (PHS) 79-1120, Aug. 13, 1979; and Vital statistics of the United States,
published annually.

still has a higher rate than 14 other industrialized
nations. Discrepancies within its own population are
noteworthy (fig. 33 and tables 26-28).
Declines in infant mortality have been attributed to
a number of changes in recent years: more women are
receiving prenatal care in early pregnancy; advanced
techniques are being used, especially in neonatology;
the most modern care is becoming more widely avail-
able through regional perinatal centers; contraceptive
utilization is improving, thereby permitting women to


Figure 33. Infant mortality rates by race, selected years, 1950-77

Infant deaths
per 1,000 live births
100
100 American Indian
,I..... Black
White
Japanese American
80 -Chinese American --



60







20--------



0 I
1950 '60 '70 '77


SOURCE: Vital statistics of the United States, published annually by the National
Center for Health Statistics, and unpublished data.
time and space their pregnancies more effectively, re-
ducing the proportion of high-risk births; legal abortion
services are increasing; programs, such as the Depart-
ment of Agriculture's Women, Infants and Children
(WIC) Program, improve the nutrition of pregnant
women and infants; and socioeconomic conditions are
generally improving (11).
In 1977 the Department of Health, Education, and
Welfare set goals to reduce infant deaths from 14.1
per 1,000 live births in 1977 to 9 per 1,000 in 1990 and
to reduce maternal mortality from 9.9 per 100,000 live
births in 1978 to less than 5 per 100,000 in 1990 (23).

Teenage pregnancy. A variety of studies have docu-
mented the educational, occupational, and other social


Table 26. Infant mortality rates (infant deaths under 1 year per 1,000 live births) by race, 1970-77


Black to
Year All races White All other Black white ratio


1970 ................ 20.0 17.8 30.9 32.6 1.83
1971 ................ 19.1 17.1 28.5 30.3 1.77
1972 ................ 18.5 16.4 27.7 29.6 1.80
1973 ................ 17.7 15.8 26.2 28.1 1.78
1974 ................ 16.7 14.8 24.9 26.8 1.81
1975 ................ 16.1 14.2 24.2 26.2 1.85
1976 ................ 15.2 13.3 23.5 25.5 1.91
1977 ................ 14.1 12.3 221.7 23.6 1.92
1978 ............... .. 13.6 .
19793 ............... 13.1 12.3 ... 23.6


I Estimated. 2 See table 32. 3 Provisional.
SOURCE: National Center for Health Statistics: Vital statistics of the


United States, published annually.


60 Public Health Reports Supplement







disadvantages of early motherhood. Young mothers'
greater risks of low birthweight infants and of perinatal
and infant mortality can apparently be mediated by
excellent prenatal care for pregnant teenagers. Their
higher obstetric risk may be "a function of the environ-
ment in which adolescent childbearing [takes] place
rather than a function of age per se" (24). Research is
being conducted on the long-term impact of adolescent
childbearing on the development of the child (including
social and emotional development, but especially cogni-
tive development) as well as on long-range adverse
educational and occupational effects on the young
mother.
Fertility rates among teenagers began to decline in
1957, first among older teens 18-19, and in 1972 among
15- to 17-year-olds as well. The U.S. teenage fertility
rate, however, remains higher than in virtually all other
industrialized societies and is a cause for continued
public concern (fig. 34). Approximately 1 million
American teens become pregnant each year; one-third
of them abort the pregnancy, and two-thirds carry it to
term. Sexual activity among teenagers has risen mark-
edly in recent years. Contraceptive use has also in-
creased, as have abortions among teens.
The National Institutes of Health's Center for Popu-
lation Research has sponsored a series of research con-
tracts to examine the causes and consequences of teenage
pregnancy. The results of these studies are being widely
disseminated to policymakers and program administra-
tors (24).
Figure 34. Fertility rates of women 15-19 years, 1920-74

Births per
1,000 women
100


80


60 Total
births

First
births
40


Second and lt"" ,
higher births 40 "+ %
- -^ - *f ,,---
...........^ ""-


I I I I
1920 '30 '40


I I
'60 '70


SOURCE: National Center for Health Statistics: Fertility tables for birth cohorts by
color, United States, 1917-73. DHEW Publication No. (HRA) 76-1152. U.S. Government
Printing Office, Washington, D.C., 1976, table 3A; 1974 data supplied by Robert L.
Heuser, Chief, Natality Statistics Branch, National Center for Health Statistics.


Increased funding for family planning services for
teenagers and for operations research on innovative
methods to provide such services have been made avail-
able through the Bureau of Community Health Services
of the Department of Health and Human Services.
Public and private programs to address the multiple
problems associated with teenage pregnancy either
stress pregnancy and birth prevention or provide medi-
cal, social, and other support services, including parent-
ing skills, for adolescents who carry their pregnancies to
term. Some programs do both. Special teenage family
planning programs include efforts to enhance the self-
esteem of teenagers in order to assist nonassertive girls
in saying "no" and boys to resist peer influence to pres-
sure their girlfriends into sexual relations. Some pro-
grams distribute free non-prescription contraceptives to
both males and females where teens congregate. Other
approaches include special teen "rap" (discussion) ses-
sions at family planning centers, and peer counseling
programs which train students to counteract inaccurate
information disseminated among their classmates.
The Center for Disease Control (CDC) surveyed a
large number of adolescent pregnancy prevention pro-
grams operated by State and local public and private
agencies and identified four of them which either
demonstrated an effect on the pregnancy or childbear-
ing rate of the teenagers in their target areas or were
unique in their intensive approach to the problem (25).
The most intensive and effective program surveyed
by CDC was a multi-service health clinic, the St. Paul
Maternal and Infant Care (MIC) Project, operated
within one or more of St. Paul's high schools since
1973. The clinic is administratively separate from the
school, and all records are private. One of its most
active services is contraception counseling, screening,
and examination. Although contraceptives are not dis-
pensed at the school, teenagers who use contraceptives
are followed monthly; students who miss appointments
are followed up. Since the program was begun, the rate
at which teenagers drop out of school after delivering
their babies has fallen from 45 percent to less than 10
percent. All young mothers who have remained in
school have accepted contraception. There were no
repeat pregnancies through 1978, and the school's fer-
tility rate fell significantly, from 79 births per 1,000
female students in the 1972-73 school year to 35 per
1,000 in the 1975-76 school year.
San Bernardino County Health Department's Youth
Counseling and Referral Program consists of one-to-one
counseling sessions with teenage women who have
visited the health department for a pregnancy test or
abortion referral. One of four full-time social workers


September-October 1980 61


20----~


^^







Table 27. Infant, neonatal, and postneonatal mortality rates (deaths per 1,000 live births) according to race, United States,
selected years, 1950-77

American Chinese- Japanese-
Mortality rate and year Black Indian American American White


Infant mortality rate:'
1950 ..................... 43.9 82.1 19.3 19.1 26.8
1960 ..................... 44.3 49.3 14.7 15.3 22.9
19702 ................... 32.6 22.0 8.4 10.6 17.8
19772 .................... 23.6 15.6 5.9 6.6 12.3
Neonatal mortality rate:3
19703 .................... 22.8 10.6 5.4 8.4 13.8
19773 .................... 16.1 8.3 4.2 5.1 8.7
Postneonatal mortality rate:4
19702 .................... 9.9 11.4 3.1 2.2 4.0
19772 .................... 7.6 7.3 1.7 1.5 3.8


I Deaths of infants under 1 year of age per 1,000 live births.
2 Excludes deaths of nonresidents of the United States.
3 Deaths of infants within 28 days of birth per 1,000 live births.

visits each teenager within 1 week of her health depart-
ment visit.
A sexuality contraception awareness program oper-
ated by the Family Planning Council of Western
Massachusetts. Inc. during the 1973-74 and 1975-76
school years is held at a vocational high school. This
program, consisting of two 2-hour sessions using a film
and small-group discussions with family-planning coun-
selors, who were also available at a nearby office for
later consultation, led to a decline of more than 50
percent in the pregnancy rate of the female students.
Since then, the school's pregnancy rate rose again after
the program was cancelled in 1976.
The fourth successful program identified by CDC
was a joint effort of the Maryland State Department of
Health and Mental Hygiene and Planned Parenthood
of Maryland which together direct a program in educa-
tion about human sexuality for adolescents in two rural
areas, including teacher-training workshops and special
training sessions for health department staff. Several of

Table 28. Infant mortality per 1,000 live births, by race
and residence

Area and race Rate

A ll areas .............. ........ ........... 15.2
White ..................... ........ .. 13.3
Nonwhite ................................ 23.5
M metropolitan ............................... 15.0
White ................. .................. 12.9
Nonwhite ............................ ... 22.8
Nonmetropolitan ............................ 15.2
White ............................... 14.0
Nonwhite ............... ... ........... 25.4

SOURCE: Ahearn, Mary: Unpublished paper on child health. U.S. De-
partment of Agriculture, 1979.


4 Deaths of infants 28 to 365 days old per 1,000 live births.
SOURCE: Division of Vital Statistics, National Center for Health Statis-
tics: selected data.

the counties included in the program experienced sig-
nificant declines in their birthrates for 15- to 17-year-
olds.
Recognizing the need to provide comprehensive serv-
ices for teenage mothers and to prevent repeat unin-
tended pregnancies among teenagers, the Administra-
tion, acting under the initiative of the President,
requested and obtained from Congress authorization to
organize the Office of Adolescent Pregnancy Programs
within the Department of Health and Human Services.
Despite public and private efforts to provide pre- and
post-pregnancy programs, many teenagers are still un-
reached.

Pregnancy in women after age 35. Many American
women have been postponing their childbearing to
late years, increasing somewhat the proportion who
give birth at age 35 or above. A primary concern at
these ages is the increased risk of giving birth to an
infant with Down's syndrome (table 29). However,
increasing use of amniocentesis to detect this and other
birth defects has reduced their incidence among those
willing to abort a fetus found to be affected. The rela-
tive risk of maternal mortality is greater among mothers
35 and older than among younger mothers, as is inci-
dence of miscarriage, toxemia, and placental abnormali-
ties. However, the absolute risks are still small (al-
though the risks increase with age, they are still quite
low).
The advantages of later parenthood (for example,
time to become established in a career, build financial
security, strengthen marriage, or fulfill personal inter-
ests before initiating family formations) are factors
which some couples see as sound reasons for delaying
pregnancy.


62 Public Health Reports Supplement







Table 29. Estimated rates of Down's syndrome in live
births by 1-year maternal age intervals for mothers aged
30-44, white live births, upstate New York, 1963-74


Reported rate Estimated rates
Maternal per 1,000 corrected for
age live births underreporting


30 ........
31 ........
32 ........
33 ........
34 ........
35 ........
36 ........
37 ........
38 ........
39 ........
40 ........
41 ........
42 ........
43 ........
44 ........


.367
.414
.623
.572
.746
1.192
1.238
1.545
2.115
2.795
3.811
4.912
7.233
5.861
4.801


1.13
1.21
1.38
1.69
2.15
2.74
3.49
4.45
5.66
7.21
9.19
11.71
14.91
19.00
24.20


1/885
1/826
1/725
1/592
1/465
1/365
1/287
1/225
1/177
1/139
1/109
1/85
1/67
1/53
1/41


SOURCE: Hook and Chambers, 1977, cited in Daniels, P., and Wein-
garten, K.: A new look at the medical risks in late childbearing. Women
and Health 4: 5-36, spring 1979.

Hysterectomy

Surgical removal of the uterus is the most common
major operation in the United States today, even
though only females are eligible. In 1975, 725,000
hysterectomies were performed, in contrast to 685,000
tonsillectomies and 318,000 appendectomies (26). Per-
formance of the operation on women between 15 and
44 years old increased 22 percent between 1967 and
1977 (11, fig. 30), but has stabilized since then. The
trend for black women to be more likely than white
women to have had a hysterectomy reversed between
1973 and 1976 (table 21).
The most commonly reported reasons for hysterec-
tomy include uterine prolapse, fibroid tumors, cancer,
excessive bleeding, or severe pelvic infection which does
not respond to medical treatment. In addition, a hys-
terectomy is performed to preclude the possibility of
developing cancer when cervical dysplasia exists; this
indication is controversial within the medical profession
and is strongly opposed by some health activists. In
1978, DHEW prohibited the use of Federal funds for
hysterectomy if the only purpose of the procedure is
sterilization. Furthermore, it required that women be
notified about the resulting sterility before a federally
financed hysterectomy can be performed, even for med-
ical reasons.

Estrogen Use
DES. The question of widespread use of hormones dur-
ing pregnancy received critical attention in the 1970s


with the appearance of a rare cancer (clear cell adeno-
carcinomas of the vagina and cervix) in the adolescent
and young adult population. As association was ob-
served between maternal ingestion of diethylstilbestrol
(DES), a synthetic estrogen sometimes prescribed to
pregnant women to prevent spontaneous abortion, and
clear cell adenocarcinomas in their daughters (27).
Estimates are that as many as 6 million Americans
(mothers, daughters, and sons) have been exposed to
DES during pregnancy.

The Registry for Research on Hormonal Transpla-
cental Carcinogenesis records details of cases of clear
cell adenocarcinoma in women born in 1940 and after.
DES treatment during pregnancy was not used before
1940. The risk for DES-exposed daughters to develop
this form of cancer is small, 0.14 to 1.4 per 1,000
through age 24.

As a result of this concern, the National Cancer In-
stitute began a study of women who had been exposed
to DES in utero. About 3,000 women in four cities are
being monitored. The Federal Government has also
funded a followup study of the approximately 1,600
women involved in a 1950-52 double-blind efficacy
study of DES. A DES Task Force was established
within the Department of Health, Education, and Wel-
fare in 1978 to review research data and make recom-
mendations.

Private consumer groups such as DES Action were
formed to disseminate current information and to focus
State government attention on the problem. Five State
programs are underway. Their activities include physi-
cian education, public information, registration of ex-
posed individuals, payment for daughters unable to
afford a screening examination, and a stipulation that
DES-exposed daughters cannot be dropped from or
refused health insurance on the basis of their DES
exposure.

The effects on mothers and sons have not yet been
thoroughly investigated. There is concern that women
who received DES during their pregnancies may have
an increased risk of breast and reproductive tract can-
cer. Information on sons has shown some abnormalities
and the need for further research. DES daughters may
have more difficulty than other women in conceiving
and maintaining a pregnancy, and their infants are
twice as likely to be born below normal birth weight.

Though no longer prescribed for pregnancy, DES is
is still used as estrogen replacement therapy and for
treatment of breast and prostate cancer. The FDA has
issued regulations that DES cannot be used as a feed
additive or subcutaneous implant in cattle (28).


September-October 1980 63







Estrogen-replacement therapy in menopause. The risks
(known and still under study) of this therapy must be
weighed against the benefits. Before 1975, when re-
searchers first identified an increased risk of endometrial
cancer among post-menopausal women using estrogen,
20 million prescriptions were filled annually. Now that
number is 6 million.
In 1979, a consensus development conference spon-
sored by the National Institute on Aging reached agree-
ment on several important points:

1. Estrogen therapy relieves vasomotor symptoms but at
present there is no evidence to justify the use of estrogens in
the treatment of primary psychological symptoms.
2. Estrogen therapy also overcomes atrophy of the vaginal
wall and associated symptoms;
3. The decision to begin therapy should depend on the
severity of symptoms and the patient's perceived need for
relief; the lowest effective dose should be utilized and, since
hot flashes naturally decline over time, unnecessary prolonga-
tion of therapy should be avoided;
4. Estrogen can retard bone loss and possibly prevent de-
velopment of osteoporosis which results in hip fractures. More
data on this are needed.
5. There are risks associated with estrogen use, including
increased incidence of endometrial cancer, which is four to
eight times more common among users of menopausal estro-
gens. The risk rises with the dose and with length of use.

While an association between breast cancer and es-
trogens has been demonstrated in experimental animal
studies, case control studies have not demonstrated an
association in humans. However, this is an area that
remains a concern and a subject of additional study
(29).
In 1977, the FDA required patient package inserts
for all estrogen products.
In April 1980, the Journal of the American Medical
Association reported the results of the first study to
confirm earlier fears that a link between long-term
postmenopausal use of estrogens and breast cancer is
"a definite possibility" (30). However, an editorial in
the same issue questions the use of retrospective case
control studies and suggests that only long-term pro-
spective studies can provided definitive answers (31).

Sexually Transmitted Diseases (STD)
The complications of sexually transmitted diseases were
summarized (32) for a 1979 conference on preventing
disease and promoting health.

Sexually transmitted diseases (STD) are infections grouped
together because they are spread by transfer of infectious
organisms from person to person during sexual contact. .
Among the serious complications caused by sexually trans-
mitted agents are pelvic inflammatory disease (PID),
conjunctivitis, infant pneumonia, infant death, mental retarda-
tion, arthritis, and central nervous system disease while
fewer than half of the infections occur in women, over 90 per-
cent of the complications accrue to them or their offspring ....


Figure 35. Reported gonorrhea cases by sex, United States,
1965-79'

Cases in 1,000s


5 '7 '9 1
'65 '67 '69 '71


'73 '75 '77 '79


SData for 1979 are estimates.
SOURCE Center for Disease Control, Department of Health and Human Services,
1980.


The most frequent complication is PID, with an estimated
annual incidence of 270,000 cases 25,000 ectopic preg-
nancies occur annually, of which an estimated 6,250 are
related to gonococcal PID.

State laws require that all cases of syphilis and gon-
orrhea be reported to the health department; there is
believed to be considerable underreporting. Cases per
100,000 population from 1950 to 1977 are shown in
table 30. Between 1967 and 1976, the number of re-
ported cases of gonorrhea increased annually by 1 to
15 percent; the yearly increase then leveled off, to less
than 1 percent (fig. 35). Incidence is related to the

Table 30. Venereal disease cases per 100,000 population,
selected years, 1950-77

Year Syphilis Gonorrhea Chancrold


1950 .......... 146 192 3
1955 .......... 76 147 2
1960 .......... 69 145 1
1965 .......... 59 169 1
1970 .......... 45 299 1
1975 .......... 33 473 < 1
1976 .......... 34 470 < 1
1977 .......... 30 466 < 1


SCURCE: Center for Disease Control, 1978.


64 Public Health Reports Supplement







changing proportion in the total population of persons
in the most susceptible ages, 15-35, as well as to changes
in sexual behavior, contraceptive methods, prevention
activities, diagnostic capabilities, reporting rates, and
availability of treatment.
From the early 1960s until 1972, Federal resources
were used solely for syphilis control; the downward
trend in reported rates of syphilis continued even after
initiation of the gonorrhea control program, but rose
by 6.2 percent between 1977 and 1978.
Unlike the aggressive population-wide screening for
syphilis undertaken during and after World War II,
syphilis screening in the 1960s was restricted to patients
seen by health care providers and to licensure situations
such as marriage and employment. Interviewing and
referral of sex contacts of persons already identified
with the disease is now the major focus of syphilis con-
trol efforts.
Gonorrhea control activities are similar, but screen-
ing is restricted to women receiving a pelvic examina-
tion; women 17-44 averaged 5-6 physician visits in
1977.
A 1976 CDC-sponsored survey found that 15 percent
of elementary schools and 71 percent of high schools
included information about STDs in their curriculum.
Gonorrhea screening and gonorrhea and syphilis con-
tact referral are supported mainly through Federal
funds provided to States under CDC guidelines-$32
million Federal dollars annually, of which $4 million
goes for public education. Local areas provided an ap-
proximately equal sum of public monies, primarily for
the operation of STD clinics. Federal money is con-
centrated on prevention and detection, while State and
local money supports clinical services.
Special programs for people who become infected
with an STD more than once and for women suffering
from gonococcal PID are being developed at CDC.
It has been estimated that the costs associated with
treatment of complications of gonorrhea in females
were approximately $212 million nationwide in 1972
(33). An estimated 50,000 women become sterile an-
nually as a direct result of gonococcal PID (Curran,
James, Center for Disease Control, unpublished esti-
mate, January 1980). The Department of Health and
Human Services has established as objectives for 1990
to reduce the incidence of gonorrhea from 1,045,000
cases in 1978 to 705,000 and of syphilis from 24,000 to
17,500 cases, to establish an adequate surveillance sys-
tem for gonococcal PID, and to reduce its incidence by
50 percent.

Education, Counseling for Reproductive Health
During the 1950s and 1960s, the topic of human sex-
uality "opened" on the American scene. It became an


acceptable subject for TV documentaries. Publications
(scholarly and otherwise) became widely available to a
broad public. Professionals in counseling professions
such as medicine, religion, and law, were confronted
with questions they were often unable to answer. Two
major developments emerged from this vastly altered
atmosphere: (a) recognition of the need to disseminate
information to the general public, which gave rise to the
Sex Information and Education Council of the United
States (SIECUS) and to the movement for the inclu-
sion of human sexuality in medical school courses and
(b) recognition of the need to provide guidance and
training for sex counselors and therapists, for which
purpose the American Association of Sex Educators,
Counselors, and Therapists (AASECT) was formed.
AASECT has provided standards, certification and,
most recently, a code of ethics.

Sex education and family life education courses,
based in schools and in a variety of other community
locations such as churches and family planning centers,
vary greatly in content and comprehensiveness. Al-
though evaluation of such courses indicates that they
enhance students' knowledge, there is a lack of evidence
thus far that they have resulted in changes in psycho-
logical health and interpersonal relations or in the re-
duction of teenage pregnancy. Although the prevention
of adolescent pregnancy may be an implicit goal, the
explicit content of many school programs has not been
designed towards that purpose. Many programs are not
permitted to include information on contraception
within the curriculum. Seventy-eight percent of the
adult American public now favors the teaching of sex
education in schools-a significant increase over the 65
percent figure recorded in 1970. The most frequently
cited obstacle to offering sex education is administra-
tors' fear of parental objections and reaction to vocal
minorities.

The Federal Government has recently funded proj-
ects that will (a) identify exemplary programs and
develop an evaluation methodology, (b) identify and
evaluate parent training programs, and (c) identify
perceived and real barriers to the implementation of
programs in sex education. CDC's Bureau of Health
Education is also attempting to identify and evaluate
sex education programs for the physically disabled and
to evaluate the role of "peer counselors" in sex educa-
tion. The Bureau of Community Health Services,
DHEW, has funded innovative programs that can serve
as models-for example, Project Teen Concern in-
cluded a school-based model in California, with junior
and senior high school curricula and teacher training
in 13 districts ("train the trainer" concept), and a


September-October 1980 65







community-based program in Tennessee that involved
the showing in 20 settings (churches and other places)
of 5-minute "trigger films" to stimulate guided discus-
sions concerning partner communication, sex stereotyp-
ing, teen pregnancy, marriage and divorce, and the
sexual problems likely when a young woman goes out
with a much older man.


References
1. Winston, F.: Oral contraceptives, pyridoxine, and de-
pression. Am J Psychiatry 130: 1217-1221 (1973).
2. McCormick, W. D.: Amenorrhea and other menstrual
symptoms in student nurses. J Psychosomatic Res 19:
131-138 (1975).
3. Beaumont, P. J., and Gelder, M. G.: Study of minor
psychiatric and physical symptoms during the menstrual
cycle. Br J Psychiatry 26: 431-434 (1975).
4. Matria, C., and Mullen, P.: Reclaiming menstruation: a
study of alienation and repression. Women and Health 3:
23-30, May-June 1978.
5. Dalton, K.: The menstrual cycle. Pantheon, New York,
1969.
6. Sommer, B.: The effect of menstruation on cognitive and
perceptual-motor behavior: a review. Psychosomatic Med
35: 515-534, November-December 1973.
7. Golub, S.: The magnitude of premenstrual anxiety and
depression. Psychosomatic Med 38: 4-12, January-
February 1976.
8. Weidegarm P.: Menstruation and menopause: the physi-
ology and psychology-the myth and the reality. Alfred A.
Knopf, New York, 1976.
9. Skultans, V.: The symbolic significance of menstruation
and menopause. In Psychology of women: selected read-
ings, edited by J. H. Williams. W. W. Norton and Co.,
New York, 1979.
10. Breit, E. B., and Myersen, M.: Social dimensions of the
menstrual taboo and the effects of female sexuality. In
Psychology of women: selected readings, edited by J. H.
Williams. W. W. Norton and Co., New York, 1979.
11. National Center for Health Statistics, National Center for
Health Services Research: Health United States 1979.
DHEW Publication No. (PHS) 80-1232, Hyattsville,
Md., 1980.
12. National Center for Health Statistics: Reproductive im-
pairments among currently married couples, United
States, 1976. Advance Data from Vital and Health Sta-
tistics, No. 55, U.S. Government Printing Office, Wash-
ington, D.C., 1980.
13. Center for Disease Control: Abortion surveillance, an-
nual summary 1977. U.S. Public Health Service, Atlanta,
Ga., 1979.
14. Benditt, J.: Second trimester abortion in the United
States. Fam Plann Perspect 11: 358-361, November,
December 1979.
15. Kessel, S. S., Rooks, J. P., and Cushner, I. M.: A child's
birthright: a population based report on reproduction and
parental and child health. Paper prepared for the Secre-
tary's Select Panel for the Promotion of Child Health,
Department of Health, Education, and Welfare, 1980.
16. Task force report. Predictors of hereditary disease or
congenital defects. National Institute of Child Health
and Human Development, Bethesda, Md., 1979.


17. Marieskind, H. I.: Women in the health care system:
patients, providers, and programs. C. V. Mosby Co., St.
Louis, 1980.
18. Marieskind, H. I.: An evaluation of Cesarean section
in the United States. Final report submitted to the Office
of Assistant Secretary for Planning and Evaluation/
Health. Department of Health, Education, and Welfare,
1979.
19. Banta, D., and Thacker, S.: Costs and benefits of elec-
tronic fetal monitoring: a review of the literature.
DHEW Publication No. (PHS) 79-3245. National Center
for Health Services Research, Research Report Series,
April 1979.
20. Hirschman, C., and Hendershot, G.: Trends in breast
feeding among American mothers. Vital and Health Sta-
tistics Series 23, No. 3, DHEW Publication No. (PHS)
79-1979, Hyattsville, Md., November 1979.
21. Martinez, G. A., and Nalezineski, J. P.: The recent trend
in breast feeding. Pediatrics 64: 686-692, November
1979.
22. National Center for Health Statistics, National Center for
Health Services Research: Health, United States, 1978.
DHEW Publication No. (PHS) 79-1232, Hyattsville,
Md., 1979.
23. Infant mortality. Draft Working Papers on Preventing
Disease, Promoting Health for a conference held in
Atlanta, Ga., June 1979. Office of Health Information,
Health Promotion and Physical Fitness, and Sports Medi-
cine, Department of Health, Education, and Welfare,
1979.
24. Baldwin, W., and Cain, V.: The children of teenage
parents. Fam Plann Perspect 12: 34-43, January-Febru-
ary 1980.
25. Center for Disease Control: Successful programs to pre-
vent pregnancy in adolescents. Morbidity and Mortality
Weekly Rep 29: 2, January 18, 1980.
26. Koepsell, T. D., et al.: Prevalence of prior hysterectomy
in the Seattle-Tacoma area. Am J Public Health 70:
40-47, January 1980.
27. Herbst, A. L., et al.: Adenocarcinomas of the vagina:
association of maternal stilbestrol with tumor appearance
in young women. New Engl J Med 284: 878-881, Apr.
29, 1971.
28. Food safety and quality service: revocation of DES.
Certification requirements. Federal Register 44: 59498-
59499, Oct. 16, 1979.
29. Office of Medical Applications of Research, National
Institutes of Health: Estrogen use and postmenopausal
women. NIH Consensus Development Conference Sum-
maries, Vol. 2, Bethesda, Md., 1979.
30. Ross, R. K., et al.: A case control study of menopausal
estrogen therapy and breast cancer. JAMA 243: 1635-
1639, Apr. 25, 1980.
31. Meier, P., and Landau, R. I.: Editorial: Estrogen re-
placement therapy. JAMA 243: 1658, Apr. 25, 1980.
32. Sexually transmissible diseases. Draft Working Papers on
Preventing Disease, Promoting Health for a conference
held in Atlanta, Ga., June 1979. Office of Health Infor-
mation, Health Promotion, and Physical Fitness and
Sports Medicine, Department of Health, Education, and
Welfare, 1979.
33. Rendtorff, R., et al.: Economic consequences of gonor-
rhea in women. J Am VD Assoc 1: 40-47, September
1974.


66 Public Health Reports Supplement








Chapter 6. The Health Care System


Not only have mortality and morbidity rates and their
causes changed, at least partly as a result of the revo-
lution in social roles in recent decades, but many
aspects of the health care system have also undergone
revision. Within the past decade there have been in-
creased proportions of women in midlevel health policy
and planning positions, and an increasing proportion
of physicians who are women. There is increased em-
phasis on encouraging consumers to engage in preven-
tive health behavior. The women's and consumer
movements have encouraged people to play more
active roles to improve the quality of their own health
care. The formation of alternative sources of care has
also affected the traditional health care system.

Women as Planners and Policymakers
While women are under-represented in the areas of
planning and policymaking, small gains have been
made in recent years. In the Department of Health,
Education, and Welfare (Department of Health and
Human Services since May 14, 1980), women consti-
tuted 8.4 percent of the personnel at the very highest


levels (grades 16-18) in 1977, and 11.5 percent by
mid-1979; the current Secretary is a woman. They
were 10.3 percent of the newly formed Senior Execu-
tive Service in 1979. However, they filled a smaller pro-
portion of top level positions in the Public Health
Service (the "H" part of DHEW) : 3.9 percent of
grades 16-18 in 1974 and 7.6 percent in 1979 (1).
DHEW advisory committees added more women and
minorities in the last quarter of fiscal year 1979 than
in the preceding 30 months; 28 percent were women
and 18 percent were minorities (up from 24 percent
and 15 percent 30 months earlier). A computer bank
of qualified candidates is being compiled to assure ade-
quate future representation.

Women are not yet represented on local health
planning agency governing boards or staffs in propor-
tion either to their numbers in the population (51 per-
cent) or to their percentage of health care providers
(80-90 percent). However, an increase in women's
participation occurred from 1976 to 1978, particularly
on professional staffs, as shown in the following table:


September-October 1980 67







Percent females on local
health planning agency
boards or stafs

Category 1976 1978
Consumers ..................... 33.1 37.7
Providers ...................... 18.4 NA
Professional staff ................ 28.7 43.4
Support staff ................... 80.6 94.2

SOURCE: Naierman, N., Wolcott, I., and Chase, H.: The
Health Resources Administration: Impact on women: an
assessment of HRA authorities and programs as they relate to
women and health. Final report on contract No. 232-78-0183,
Hyattsville, Md., 1979.

In medical schools, no women served as vice-presi-
dents for health affairs among 5 such positions nation-
wide in 1955 and, by 1978, there were still no women
in these positions that numbered 71 by that year (table
31). In 1978 no women were counted among the
country's 115 medical school deans, although there has
been some increase in female associate and assistant
deans.
In 1980 only 1 Congresswoman (of 37 representa-
tives and senators) serves on a committee concerned
with health issues: Rep. Barbara Mikulski of Baltimore
is on the Health and Environment Subcommittee of the
Interstate Commerce Committee of the House of Rep-
resentatives. No female members are on the influential
Labor and HEW Subcommittee of the Appropriations
Committee or the Health Subcommittee of the Ways
and Means Committee.
The Bureau of Labor Statistics reports that in the
United States in 1979, of 55,000 persons classified as
biological scientists (including teaching and research),
63.6 percent were male (unpublished data, U.S. De-
partment of Labor, 1980). Males represented 80.4 per-
cent of the principal investigators funded in extramural
projects in 1979 by the Center for Population Research
(CPR) at the National Institutes of Health. The dis-
tribution of the Center's extramural principal investi-
"ators by sex in 1979 follows:


Figure 36. Trends in the number and percent of residencies
filled by women and blacks for selected years, 1968-77


Thousands of
residencies
Percent filled by women
Number filled by women
8 Percent filled by blacks
Number filled by black
"""*" Number filled by blacks


Percent of
residencies
13


12


11


2-

..f...l*"

0 I I I I I I I I
1968 '70 '72 '74 '76 '77


-10


- 9
Z
z
3


-2


1

0


SData for 1977 unavailable in March 1979.
SOURCE: Annual reports of medical education in the United States for 1968-1969;
1970-1971; 1972-1973; 1974-1975; 1976-1977; and 1977-1978 (in press), JAMA,
Chicago, Ill.


Category Number Percent
Total CPR . . . . .. 757 100.0
Male . . . . . ..... 609 80.4
Female . . . . ..... 148 19.6
Biomedical sciences ... .. ... .. 614 100.0
Male . . . . . ..... 506 82.4
Fem ale . . . . . 108 17.6
Behavioral and social sciences ....... 143 100.0
M ale ......................... 103 72.0
Female ....................... 40 28.0

SOURCE: Lewereng, George, Center for Population Re-
search, National Institute of Child Health and Human Devel-
opment, unpublished data, April 1980.


Table 31. Female representation in senior administrative positions in U.S. medical schools, 1955-78

Number of women In total
Year Vice president,
health affairs Full dean Associate dean Assistant dean Department head Division head

1955 ............ O of 5 1 of 89 0 of 31 1 of 61 7 of 1,084
1965 ............ of 27 0of 109 1of 87 6 of 115 10 of 1,351 2of 211
1969-70 ......... 0 of 39 0 of 110 3 of 173 5 of 111 9 of 1,379 16 of 1,308
1972-73 ......... 0 of 48 0 of 111 7 of 226 7 of 131 12 of 1,616 24 of 1,454
1976-77 ......... 0 of 72 0 of 115 10 of 298 12 of 155 21 of 1,736 64 of 1,877
1977-78 ......... 0 of 71 0 of 115 15 of 331 17 of 171 26 of 1,672 59 of 2,034


SOURCE: Ferrell, K., Witte, M. H., Holguin, M., and Lopez, S.: Women physicians in academia: a national statistical survey. JAMA 241: 2811, June
29, 1979.


68 Public Health Reports Supplement








Figure 37. Women as a percent of first-year enrollees in U.S.
medical schools, 1969-76


Percent
25


20


15


10


5

1969 '70 '71 '72 '73 '74 '75 '76

SOURCE: 77th Annual report, medical education in the United States, 1976-1977.
JAMA 238: 2771, Dec. 26, 1977.

Women as Health Care Providers
Between 1963 and 1976, the number of professionally
active women physicians increased from 14,957 (5.7
percent of all active physicians) to 28,966 (8.3 per-
cent), according to the Graduate Medical Education
National Advisory Committee (2). Although this is
one of the lowest proportions in the world (3), the
proportion of U.S. physicians who are women can be
expected to continue to increase. The percentage of all
residencies filled by women rose from 9.4 percent in
1968 to 13 percent in 1976 (fig. 36) ; and the percent-
age of medical schools' entering classes who are women
rose from 9.2 percent in 1969 to 24.7 percent in 1976
(fig. 37).
In 1978, only 1.7 percent of practicing dentists were
women. This statistic, too, can be expected to change,
as 11.2 percent of the entering class in dentistry schools
in 1978 were women.
First year enrollment of women in selected health
professions schools for 1978 was as follows:

Percent
Professional school female
M medicine .................................... 22.4
Osteopathic medicine .......................... 11.5
D entistry .................................... 11.2
Optom etry .................................. 13.4
Pharm acy ................................... 36.8
Podiatry .................................... 7.1
Veterinary medicine ....................... 28.2
N ursing ..................................... 94.0

SOURCE: Federation of Organizations for Professional
Women, 1980.


The proportion of women enrolled in schools, of
osteopathic medicine rose from 2.7 percent in 1968-69
to 8.5 percent in 1974-75. Females constituted only 2.9
percent of the student body in schools of optometry in
1969-70, but were 5.1 percent in 1972-73. The pro-
portion of females in schools of pharmacy rose from
18.2 percent in 1968-69 to 30.4 percent in 1974-75. But
in schools of podiatry, women were only 1.5 percent of
total enrollment in 1972-73. (4). Women students in
schools of public health increased from 46.2 percent in
1974-75 to 51.2 percent in 1978-79 (Oakley, Deborah,
University of Michigan School of Nursing: Teaching
and research on women's health issues in schools of
public health. Unpublished paper, 1979).
The Health Professions Educational Assistance Act
requires medical schools receiving Federal assistance to
establish a reasonable number of shared-schedule resi-
dency positions. Such arrangements, enabling two peo-
ple to share a residency slot and duty hours, can have
a beneficial impact on women or men who combine a
medical career with family obligations.
Preliminary findings reported by the Association of
American Medical Colleges (AAMC) from a longi-
tudinal study of medical school students who gradu-
ated in 1960 indicate that female physicians are more
likely than male physicians to specialize in family
practice, internal medicine, and pediatrics.
The Journal of the American Medical Women's
Association (5) has reported that 40 percent of all
female physicians chose primary care specialties com-
pared to 28 percent of all male physicians.
That women are moving rapidly into obstetrics and
gynecology is evidenced by the fact that in 1979-80,
37 percent of the first-year residents were women. In
1974, only 13 percent of obstetrics-gynecology resi-
dencies were filled by women; the percent female has
increased about 5 percent each year.
Data from the AAMC study also indicated that
women physicians averaged 47 hours per work week
compared with 57 for men, and most women physicians
reported incomes of $35,000 to $39,999 compared with
$40,000 to $59,999 for men. Twenty-two percent of
the women earned less than $25,000 compared to 1.7
percent of the men.
In the late 1970s, women comprised 75 to 80 per-
cent of the health workforce: 86 percent of health aides,
97 percent of practical nurses and registered nurses,
and 71 percent of health technicians (6).
Enrollment of women in 1975-76 in junior and senior
college training programs in selected allied health
occupations follows:


September-October 1980 69








Occupation female
Total ............................... 75.3

Health care administrator, assistant ............. 45.1
M medical or dental secretary ................... 98.9
M medical office assistant ....................... 98.4
Biomedical engineer .......................... 17.3
Biomedical engineer technician ................. 4.6
Medical laboratory assistant, technician .......... 81.6
Chemistry technologist ........................ 22.0
Dental assistant ............................. 99.4
Dental hygienist ............................. 98.1
Dental technician ............................ 31.9
Nurse anesthetist ............................ 63.0
Nurse midwife .............................. 100.0
Nurse practitioner ........................... 93.7
Nurse aide, orderly ........................... 94.5
Operating room technician .................... 86.4
Geriatric care worker ......................... 63.5
Physician assistant ........................... 35.8

SOURCE: Federation of Organizations for Professional
Women, 1980.

The Health Resources Administration of the Depart-
ment of Health and Human Services has a continuing
grant activity entitled the "Health Careers Opportunity
Program," the main objective of which is to assist the
disadvantaged of both sexes. The grant guidelines state
that women are considered "disadvantaged" if they
are in the minority for a specific profession which is
the case in medical, dental, and many other health
professions (7).
Relative to other occupations dominated by females,
turnover in the nursing profession is very high. Carol
Weisman and colleagues at Johns Hopkins University
School of Hygiene and Public Health studied 1,500
nurses in two large university hospitals and concluded
that turnover rates could be attributed largely to ele-
ments of job dissatisfaction related to factors such as
the lack of autonomy and the amount of supervision,
which are associated with nursing's development as a
sex-segregated female profession in a field dominated
by males (unpublished data, 1980).
Lack of autonomy in traditional nursing roles may
be one major reason that many nurses seek additional
training to prepare them for roles as nurse-practitioners
and nurse-midwives-two rapidly growing health pro-
fessions. The essence of the nurse-practitioner and nurse-
midwifery movements is assumption of responsibility by
nurses for management of areas of health care which
either do not require medical diagnosis and treatment
of disease (for example, normal pregnancy), or within
which most of the required medical care can be rou-
tinized and is needed by people who also need nursing.
Examples of "nursing care" include education, coun-
seling, assistance, and direct care aimed at health pro-
tection and promotion or at meeting the individual's


basic physical, emotional, and social needs during ill-
ness or other alterations in health status. Rooks
described recent changes (8): certification programs
for nurse-midwives are of long standing (more than 20
years), while those for nurse-practitioners have only
recently been introduced. In 1978, an estimated 12,000
nurse-practitioners were practicing in the United States,
and more than 600 nurse-midwives were in active
clinical nurse midwifery practice at the end of 1976.
More than 30 States have revised their laws to allow
diagnosis and treatment by nurses under special rules
and regulations.
Although support for developing nurse-midwifery
services and nurse-practitioner roles was originally
based on their service to rural and inner-city popula-
tions without adequate access to physicians' care, both
groups now serve a broad cross-section of society.
Lack of medical and private health insurance reim-
bursement for services performed by nurse-midwives
and nurse-practitioners remains an unresolved issue.

Women as Consumers of Health Care
Use of service. Women are the primary consumers of
health care, both for themselves and for their families.
The pattern of utilization, however, is mixed and varies
greatly with age.
Although males have more operations than females
at younger and older ages (less than 15 years and 65
and older), women between 15 and 44 have consider-
ably more operations than men of those ages. Most of
the difference can be accounted for by Cesarean section
deliveries, dilation and curettage, and hysterectomies.
The incidence of inpatient operations performed in
non-Federal short-stay hospitals per 1,000 population
in 1966-67 and 1976-77 was as follows:


Age (years)
Under 15 .....
15-44 ........
45-64 ........
65 and older ...


Male

1966-67 1976-77
46.7 47.2
54.9 58.3
81.8 104.6
129.8 184.3


Female

1966-67 1976-77


34.1
1115.4
116.7
104.0


34.5
S143.5
140.9
143.8


Both sexes .... 78.4 94.5

1 Includes Cesarean section, dilation and curettage, hysterec-
tomy, and others (see Chapter 5. Reproductive Health, con-
cerning recent increases in these procedures).
SOURCE: National Center for Health Statistics, Hospital
Discharge Survey.

Females at the youngest and oldest ages also have
fewer days of hospital care than men, but they exceed
men in the middle years. Only part of the difference
can be attributed to childbirth. Days of care in non-


70 Public Health Reports Supplement







Federal short-stay hospitals per 1,000 population for
1972 and 1977 follow:


Age
Under 15 years ..
15-44 ..........
45-64 .........
65 and older ....


1972

Male Female
372 283
612 1,142
1,633 1,645
4,249 3,945


Both sexes ...... 1,188

SDeliveries account for 259 days.
SOURCE: National Center for Health
Discharge Survey.


Male Female
350 265
621 11,065
1,679 1,697
4,282 4,068
1,183


Statistics: Hospital


Although below the age of 15 boys make more physi-
cian office visits than do girls, adult women make more
physician office visits than do men. Data on office visits
to physicians, per 1,000 population in 1973 and 1977,
follow:


Male


Female


Age groups (years) 1973 1977 1973 1977
All ages .......... 2,360 2,239 3,280 3,067
Under 15 ............. 2,043 2,050 1,907 2,003
15-44 ................ 1,852 1,713 3,520 3,168
45-64 ................ 2,959 2,812 3,985 3,737
65 and over ........... 4,180 3,799 4,875 4,391

SOURCE: National Center for Health Statistics, National
Ambulatory Medical Care Survey.

In 1977, women aged 15 or more made an average
of 3.5 visits to office-based physicians (3.6 visits for
white women, 2.7 for nonwhite women), compared
with 2.2 visits per male; the sex difference pertained
regardless of age (National Center for Health Statistics,
National Ambulatory Care Survey). Some of the dif-
ferences are due to increased numbers of visits associ-
ated with advancing age, and the greater number of
women than men at older ages.
Women are more likely than men to use Medicare
services (571 services per 1,000 female enrollees, com-
pared with 531 for males in 1976). Reimbursement for
physician services in 1976 averaged $297 per user. Of
this amount, the average for male beneficiaries was
$334, and for female beneficiaries it was $273. Reim-
bursement for inpatient hospital services in 1976 aver-
aged $2,107 per reimbursed user (men $2,150, women
$2,074). It should be noted that physician and inpatient
hospital services account for over 90 percent of all
Medicare reimbursements, with hospital services by far
the most important in terms of money expended. A
higher proportion of enrolled women (56 percent)
received reimbursement for physician services than men
(52 percent), and a higher proportion of enrolled men
received reimbursement for inpatient hospital services


(24 percent men, 22 percent women). The average
Medicare reimbursement for physician, inpatient hos-
pital, and all other covered services in 1976 was higher
for men ($1,361) than for women ($1,122). However,
because more women than men are enrolled in Medi-
care, total reimbursements for care received by women,
$8.9 billion, exceeded costs associated with care for
men, $6.8 billion, in 1976 (9).
Three out of four (74) percent of nursing home
residents aged 65 and older in 1977 were women. This
is mainly due to the discrepancy between male and
female life span, but also to the greater likelihood of a
woman to care for an elderly spouse in the home than
for the reverse to be the case (see also, Chapter 7, Spe-
cial Concerns, Older Women).
Although women are more likely than men to report
that they have a regular source of health care (85 per-
cent compared with 76 percent), they are also more
likely to perceive that they have unmet health needs.
Among people without a regular source of health care,
women are more likely to indicate that they are unable
to find the right physician. Before menopause, women
receive health care primarily from obstetricians and
gynecologists; after age 45 they are cared for primarily
by internists and family physicians (10).

Insurance. The current situation can be summarized:

Pregnancy as a disability. A Supreme Court deci-
sion in 1978 (Gilbert v. General Electric) stated that
an employer did not have to treat pregnancy as other
illnesses since women were not thereby denied a benefit
given to men. However, this decision was reversed by
an act of Congress, the Pregnancy Discrimination Act
of 1979 (an amendment to the Civil Rights Act of
1964). The law now requires that insurance programs
which compensate employees for time missed due to
illness and disability must also compensate employees
for time missed due to childbirth.

Maternity benefits. These benefits are optional in
some insurance plans. When offered, they usually re-
quire a higher premium. Women may have to be en-
rolled at least 10 months before they are entitled to ma-
ternity benefits, even, in some cases, to care for prema-
ture deliveries or miscarriages (11).

Marital status. Insurance plans for single women
are changing; maternity is still poorly covered by most
plans, but the Pregnancy Discrimination Act has
prompted some changes. Single-person contracts cover
only one person, whereas additional family members-
such as a newborn baby-can be added only to a family
contract.


September-October 1980 71







Although married women can obtain single-person
insurance coverage, it is less costly for all members of
a family with children to be covered as dependents of
one employed spouse under work-based plans. When
women covered under their husbands' policies divorce
or are widowed, they lose their coverage.

Breast cancer. Although insurance coverage for
post-mastectomy reconstructive mammoplasty and
breast prostheses is increasing, they are not covered by
many insurance policies, even though artificial limbs
usually are covered.
Exclusion of preventive care. Women's access to
breast and cervical cancer screening and to family
planning services is affected by exclusion of routine or
preventive health care under some policies.
Home care. Some policies which will pay for a
visiting nurse will not pay for a home health aide,
although Medicare does. Since women traditionally
assume the role of family "nurse," this exclusion causes
some women to leave their jobs in order to stay home
to care for other family members.
"Experience rating." Although race has been
eliminated as a basis for tables used to calculate rates
and benefits, sex is still used. Reproductive health
services account for a large proportion of women's
greater use of health services. This allows policies
which cover women to charge higher premiums, a
consideration which could discourage companies from
hiring women (Harrison-Clark, Anne: Health insurance
issues as they affect women. Unpublished paper of the
Population Resource Center, Washington, D.C., 1979).
Reimbursement for nonmainstream providers. The
majority of private third party insurers will not cover
services provided by chiropracters, certified nurse mid-
wives, nurse practitioners, physicians' assistants and
others.

The U.S. Congress is currently considering several
proposals for national health insurance (NHI). The
preceding section highlights some of the issues for
women regarding current coverage or lack of it. These
issues will receive critical attention as NHI proposals
are weighed. The following are particular concerns.

-That NHI not be solely for "catastrophic" illness, but
include routine curative care and preventive care as
well;
-That NHI include comprehensive coverage for re-
productive health care:
-That NHI provide incentives for home care for the
chronically ill as one means to contain hospital and
nursing home costs;
-That NHI cover individuals in their own right, not


as dependents of employees, and that coverage not be
work-based, so that women will not lose coverage either
when they lose eligibility as spouses through divorce or
widowhood or when they lose eligibility as employees
because of their greater likelihood of entering, leaving,
and re-entering the labor market, especially during
reproductive years.

Access to health care. Even when health services are
available, the manner in which they are provided may
limit access to them for some women. "Access" includes
the provision of service at convenient hours, within
reach by public transportation, without language bar-
riers to block communication between provider and
consumer, and within the financial capabilities of those
who need services. Access also includes appropriateness,
comprehensiveness, and acceptability of services to
health care consumers.

Access to contraceptive services. The contraceptive
methods used by the majority of American women
cannot be purchased over-the-counter in a pharmacy
and require some form of medical care and supervision.
The need for medical attention can entail inconven-
ience, expense and, especially for young women, a con-
cern about privacy.

Access to abortion services. Access to abortion is con-
centrated in the largest urban areas, particularly on the
east and west coasts (12). For women in the Rocky
Mountain States, the Midwest, and South, obtaining
an abortion requires the ability and money to travel
long distances. In six States, for example, no abortions
were performed in nonmetropolitan areas in 1975. Eight
other States reported fewer than 100 abortions in all of
their nonmetropolitan areas. It is estimated that about
260,000 to 770,000 women were denied abortion serv-
ices in 1975 due to lack of access (13).

Free-standing clinics have played an increasing role
in making early abortions more accessible to some urban
women, but they require a substantial population base
to be economically viable.

Access to services for rape victims. In most communities
one hospital, usually the public hospital if there is one,
is designated to treat all victims of rape. Other hospitals
will often refuse to accept rape victims for treatment.
Victims of sexual assault have been profoundly trauma-
tized and need special and sensitive care. What is
needed is not always provided in public hospital emer-
gency rooms, which sometimes lack adequate private
examining rooms, effective procedures for obtaining all
relevant physical evidence, and specially trained per-


72 Public Health Reports Supplement







sonnel to deal with the physical and emotional trauma
women experience after rape. Hospitals and physicians
are reluctant to become involved in court cases; they
are also fearful of being sued for negligence and
incomplete evidence. Also, the attitude of society to-
wards rape-that many women "ask for it"-is re-
flected in many physicians' and nurses' attitudes. Vic-
tims of sexual assault may experience apathy or hostility
from medical personnel (14).
This situation has begun to change, but progress is
slow. Under the impact of increasing publicity about
hospital neglect, more hospitals now receive rape vic-
tims. Although some are providing better care, the
extent of appropriate medical care and followup serv-
ices available to women through hospital emergency
services is limited. Community mental health centers
have only begun to address the concerns of rape vic-
tims; federally funded centers are required to provide
consultation and education services related to rapes.
Although some provide these mandated indirect serv-
ices, very few offer direct services to rape victims (15).
(See Chapter 4. Other Health Concerns, for informa-
tion on women-run rape crisis centers.)

Access to drug and alcohol services. Women are ex-
cluded from certain types of drug and alcohol programs
and face significant barriers to other kinds of substance
abuse services. Naomi Naierman (15) found that 29
percent of federally funded drug and alcohol programs
reserved all of their residential slots for men only and
an additional 58 percent reserved about three-fourths of
their slots for men. The reasons for such an imbalance
in these programs were sex differences in past utiliza-
tion patterns or the physical design of the residential
facilities. Some facilities would have required substan-
tial renovation to accommodate women, while main-
taining privacy between the sexes.
Among drug and alcohol centers offering outpatient
services, sex differences in utilization patterns are indic-
ative of other access barriers facing women. Naierman
(15) found that women are greatly outnumbered in
drug and alcohol programs because of several interre-
lated factors. First, "gatekeepers" such as physicians,
police, courts, and health and mental health agencies
are either not sensitized to detect substance abuse in
women or are reluctant to refer them to appropriate
treatment programs because of a protective societal
attitude. Secondly, many women have been discrimi-
nated against in drug and alcohol programs, and this
experience has discouraged them from trying again.
Thirdly, women are generally isolated and are less
aware of available services and more reluctant to seek
community services.


Consumer-Providers
When women work as physicians, nurses, pharmacists,
and other health care professionals, it is clear they are
acting in the role of "provider" of health care. When
they purchase or otherwise obtain medical services,
they are "consumers." The distinction becomes blurred,
however, in certain behaviors associated with preven-
tive health care and when consumers take onto them-
selves certain behaviors that have traditionally been
considered the province of the medical profession.

Disease prevention and health promotion. Disease pre-
vention and health promotion in the United States has
assumed a new priority at many levels, from President
Carter and the Surgeon General of the U.S. Public
Health Service (16), to an array of private and volun-
tary efforts including health promotion clinics and semi-
nars, workshops, health food stores, exercise centers, and
expanded programs of participant sports. Although some
of the current emphasis is still on trim figures and
muscle tone for the long-accepted reasons of good ap-
pearance, there is also a new emphasis on developing
good habits, and giving up harmful ones, for a sense of
well-being. For some women, getting involved in active
sports has required overcoming a lifetime of socializa-
tion to believe that strenuous activities and strong mus-
cles are not "ladylike," reinforced by lack of emphasis
on team activities for young girls and lack of access
to sports facilities and financial support for women's
athletics.
In 1978, a large nationwide study of American
adults' health knowledge, attitudes, and practices was
undertaken (17). The major findings were that:

7 in 10 adults believe that Americans today are
more concerned about preventive health than a few
years ago;
6 in 10 adults are "concerned" (as compared with
complacent) and do not take good health for granted;
About 2 in 3 adults do not exercise regularly;
Many feel there is too much emphasis on taking
mood-altering drugs;
8 in 10 indicate a need to have less stress in their
daily lives (especially low-income families and single
parents, most of whom are women) ; and
Despite their interest and concern, most feel they
are not well-informed about nutrition, mental health,
and other matters of preventive care.

Important sex differences were observed in this study.
Women were more likely than men to consider them-
selves well-informed (63 percent of this group are
female) and women are more likely than men to be
"concerned" rather than "complacent" (table 32).


September-October 1980 73







Table 32. Major differences in the
and the complacent, in p

Feel a strong need to-


Be in better physical shape ........
Have less strain in their daily lives ..
Have closer ties to their families ....
Understand themselves better ......
Be fulfilled as individuals .........
Be respected by their neighbors ....
Get more sleep and rest ...........
Be successful and outstanding .....
Be more attractive physically ......
Have closer ties with their doctors ..

1 63 percent of this group are women.
SOURCE: Clark. R., and Barren. D. D.:
family report, 1978-1979: family health in an
Minneapolis, Minn., 1979.


needs of the concerned The numbers of women participating in intercollegi-
ercentages ate athletics have more than doubled since 1972. A

1977 study of 42 women's college athletic programs
Concerned 1 Complacent showed growth in women's athletics independent of

program expansion resulting from title IX.
48 36 There has been a tremendous increase in college
43 36 athletic scholarships for women. Six years ago, only
40 34
40 35 60 U.S. colleges offered athletic scholarships to women;
36 27 today, 500 do so. The new title IX athletic regulations
35 28 released in December 1979 by DHEW stated that schol-
31 20
24 19 arships must be available to men's and women's athletic
20 15 programs in proportion to the number of male and
13 4 female participants in athletics (19).
Six years ago the women's sports budget of the "Big

The General Mills American 10" midwestern colleges averaged approximately
era of stress. General Mills, $3,500. In 1977-78, their women's sports budgets
ranged from $250,000 to $750,000 (20).


From national surveys conducted by the National
Center for Health Statistics, we find that only 57 per-
cent of women over age 40 have had an electrocardio-
gram, compared with 65 percent of men. Of women
aged 17 and older, 21 percent have never had a Pap
test, mainly women 65 and older; 24 percent have never
had a breast examination (table 33).

Table 33. Percent distribution of women 17 years and over
by whether they had ever had a breast examination or Pap-


Age (years)


17-24 ............
25-44 ............
45-64 ........ ...
65 and older ......


anicolaou test, oy age group, 1


Breast Pap
examination test
only only

7.3 3.1
2.2 2.9
4.8 4.6
10.0 4.9


Many women continue to pursue sports after high
school and college. Fifty-three percent of the nation's
fitness enthusiasts are women. Of the 14 million tennis
players in the United States, 6.5 million are women; of
the 17.1 million joggers, 6.5 million are women; and
of the 20.2 million bowlers, 9.7 million are women. In
the 1971-75 Health and Nutrition Examination Survey
(HANES), men and women reported the following:


Self-reported degree of exercise


Male Female


l9u3 Very active, had much exercise ........ 63.6 50.9
Somewhat active, had some exercise .... 31.1 42.3
Inactive, had little or no exercise ....... 5.3 6.8
Both Neither
SOURCE: Health and Nutrition Examination Survey I,
National Center for Health Statistics.


57.5 27.0
86.4 5.2
73.4 12.1
48.0 29.7


Total ....... 5.2 3.8 70.7 15.5

SOURCE: National Center for Health Statistics: Use of selected medical
procedures with preventive care, United States, 1973. Vital and Health
Statistics, Series 10, No. 110, March 1977.

Sports and exercise. Title IX of the Education Act of
1976 prohibits educational institutions receiving Fed-
eral funds from practicing sex discrimination. A great
deal of attention has centered on the implications of
this legislation for women's sports. The act has been
credited with stimulating increased funding for and
interest in women's athletics, although the legally ac-
ceptable allocation of resources between men and
women is still at issue.
The most recent figures of the National Federation
Sports Participation Survey indicate there are more
than 3.7 million male and 1.9 million female partici-
pants in athletics on the high school level (18).


Women lagged behind men in the amount and regu-
larity of exercise they reported. However, by 1978-79,
a privately conducted survey (17), asking questions that
differed from those in HANES, found women only
slightly less likely than men to be regular exercisers.
Working women were more likely than nonworking
women (and as likely as all men)-37 percent-to
exercise regularly. Coupled with increased emphasis
on health promotion activities, Department of Health
and Human Services goals for 1990 include increasing
the population of regular exercisers to 75 percent, with
special emphasis on women, inner-city and rural resi-
dents, and the poor (21). Nevertheless, despite recent
publicity about running and fitness, when American
families were asked in 1978-79 whether they were then
exercising more or less than they had a year earlier,
those exercising more barely outnumbered those exer-
cising less.

Nutrition. Overconsumption of fats, salt, and alcohol
has been related to 6 of the 10 leading causes of death,


74 Public Health Reports Supplement







namely heart disease, stroke, cancer, diabetes, arterio-
sclerosis, and cirrhosis of the liver. (The role of sugar
in mortality from these causes is suspect, but not defi-
nitely proven.) Diet is also believed to contribute to
hypertension, which is a risk factor for heart disease
and stroke (22).
Inadequate nutrition is associated with poor preg-
nancy outcome including some fraction of low birth
weight infants, children not realizing full physical and
mental potential, and suboptimum growth as measured
by length or height for age, and weight for length or
height.
HANES-I findings indicate that women are more
likely than men to suffer deficiencies in niacin, vitamin
A, fatty acids, iodine, and calcium. Iron and folic acid
deficiency is particularly common in women; DHHS
prevention goals for 1990 include a 50 percent reduc-
tion in the prevalence of this deficiency (21). Iron in-
take is below the recommended daily allowance for all
females, regardless of age. Protein intake is below the
recommended daily allowance for adult black women
and older white women. Mean calcium intake for adult
females approaches or falls below the standard (22).
What is being done, publicly and privately, about
nutrition? Compared to a year ago, American family
members believe that they are eating more nutritiously
and counting calories more attentively now; more
women than men reported eating a more nutritious
diet (17).
A U.S. Senate Select Committee on Nutrition and
Human Needs, chaired by Sen. George McGovern,
issued Dietary Goals in February 1977. A task force
organized by the American Society for Clinical Nutri-
tion (ASCN) examined all available scientific evidence
on six dietary issues that are thought to bear heavily
on the prevalence of arteriosclerotic disease, diabetes,
hypertension, liver disease, dental caries, and obesity.
The resulting consensus document, which can be of
help to public officials in formulating national nutrition
policies, was presented in a public symposium in May
1979 (23).
The major emphasis of many nutrition programs is
on diabetes, obesity, and anemia, all of which affect
women more severely than men.
The Center for Disease Control is developing a sur-
veillance mechanism to monitor the nutritional status
of pregnancy. Indicators will include maternal height,
pre-pregnant weight and weight gain, hemoglobin or
hematocrit, term of pregnancy, birth weight, and
various risk factors affecting birth weight. These will
provide estimates of nutrition-related problems.
The Office of Maternal and Child Health, Bureau of
Community Health Services, Department of Health


and Human Services, provides grants for comprehen-
sive health services, including nutrition assessment,
evaluation, and counseling for pregnant women and
their infants.
Title III of the Older Americans Act provides for
nutrition services for people aged 60 and older and
their spouses. Meals are provided in group settings or
are delivered to the homebound.
In fiscal year 1982, the DHHS Center for Popula-
tion Research plans to examine the role of nutrition in
the maintenance of reproductive health and fertility.
The Bureau of Community Health Services' Office of
Family Planning has funded several demonstration
programs to incorporate nutrition education into family
planning services.
The Women, Infants and Children (WIC) program
provides supplementary foods for pregnant women and
children under 5 years. (See Chapter 5 on pregnancy
outcome.)
Participants at a national conference on directions
for nutrition education in the 1980s recommended that
(a) a presidential or congressional nutrition advisory
committee be established by January 1981, (b) uni-
versities develop both "creative" nutrition education
programs and programs to certify nutrition educators,
and (c) teaching or learning about nutrition be desig-
nated a reimbursable health service for health profes-
sionals and the general public. The conference, held in
September 1979, was sponsored by DHEW, the Agricul-
ture Department, the Federal Trade Commission, the
White House Office of Science and Technology Policy,
and the Society for Nutrition Education. Separate task
forces issued recommendations on nutrition education
for pregnant women, children, and adolescents; the
general public; low-income populations and the elderly;
and for persons with diet-related diseases.

Obesity. Obesity is related both to nutrition and to
exercise. It is more prevalent among women, especially
nonwhite women, than men. Interestingly, while poor
women of both races are slightly more likely than non-
poor women to be obese, and obesity is considerably
more common among black than white women, regard-
less of income, the opposite relationships are observed
among men (table 34). White men are somewhat more
likely than black, and nonpoor men more likely than
poor men to be obese. The age associations are also re-
versed between sexes. The peak years for obesity in
women are the middle ages (45-64), whereas for men,
the highest rates of obesity are in men 20-44. Variation
by age is much more pronounced among women than
among men. Poor black women 45-64 are most likely
of all (49.4 percent) to be obese.


September-October 1980 75







Table 34. Percentage of obesity among persons 20-74 years, by sex, race, age, and poverty level, United States, 1971-74


Male Female
Age and poverty level
All races I White Black All races 1 White Black

All ages 20-74 years ................ 13.0 13.3 11.6 22.7 21.8 31.2
Below poverty level ............... 8.0 8.2 7.6 26.5 23.1 33.3
Above poverty level ............... 13.8 13.9 13.4 22.6 22.1 30.0

20-44 years ........................ 14.2 14.2 13.3 19.7 18.4 25.6
Below poverty level ............... 9.7 9.4 11.1 22.8 20.6 27.6
Above poverty level ............... 14.7 14.9 14.6 18.8 18.3 24.0
45-64 years ........................ 12.1 12.2 10.2 29.0 27.6 43.0
Below poverty level ............... 4.8 5.3 3.7 35.1 26.4 49.4
Above poverty level ............... 13.2 13.2 12.4 29.2 28.5 40.0
65-74 years ........................ 11.0 11.5 5.8 20.5 19.8 27.7
Below poverty level ............... 9.1 10.3 4.6 24.7 25.2 23.2
Above poverty level ............... 10.8 11.1 7.0 20.1 19.2 36.3


I Includes all other races not shown separately.
NOTE: Data are based on physical examination of a sample of the
civilian noninstitutionalized population. Obesity measure is based on
triceps skinfold measurements and is defined as falling above the sex-

In contrast to actual skin-fold measurement of
obesity as reported in the HANES, self-perception of
"overweight" is reported by the Health Interview Sur-
vey. In 1974, 30 percent of males and 49 percent of
females reported themselves as overweight. White
women were more likely than black women-50 per-
cent compared with 44 percent-to perceive themselves
as overweight (22). American families interviewed in
1978-79 (17) tended to regard underweight as a health
problem but overweight as a personal emotional weak-
ness.
DHHS goals for 1990 include the reduction by 1
percent per year in mean body weight of adults (with-
out nutritional impairment) and an increase of 100
percent in programs to prevent obesity in primary
school children.

Self-care. "Self-care" and "self-help" are terms that are
sometimes used interchangeably, but health activists
and medical social scientists point out their differences.
Levin, cited in Kronenfeld (24), defines self-care as:

a process whereby a lay person can function effectively on his
own behalf in health promotion and prevention and in disease
detection and treatment at the level of the primary health
resources in the health care system.
Katz and Bender, quoted by Kronenfeld (24), define
self-help as:

voluntary small group structures for mutual aid and the ac-
complishment of a special purpose. Self help groups
emphasize face-to-face social interaction and the assumption
of personal responsibility by members.

Alcoholics Anonymous is a well-known example of a
self-help, mutual assistance group.


specific 85th percentile measurements for persons 20-29 years of age.
SOURCE: Division of Health Examination Statistics, National Center for
Health Statistics: Data from the Health and Nutrition Examination Survey.


Although individual or group emphasis on self-care
and self-help have existed over many years, during the
1960s and 1970s these activities received particular
impetus in the United States from several sources: a
growing consumer movement that encourages improved
public knowledge and awareness relative to the pur-
chase of goods and services and that presses for greater
sensitivity to the public's needs on the part of providers;
the women's movement, which has focused a great deal
of public attention on inequities in health care; and a
health activist movement that sought to promote
healthy eating habits, stress management, and other
practices.
All of these movements underscore the importance of
individuals taking responsibility for their own lives and
well-being, and all of them developed from a sense of
dissatisfaction with existing institutions and with a sys-
tem that was felt to be unresponsive to consumers'
needs.
Self-care has been described as "a combination of
preventive health care and super first-aid"; most realis-
tically it combines education in good nutrition and
health habits with education in the proper recognition
and handling of self-limiting or untreatable diseases
and conditions.
Many conditions for which persons seek professional
medical attention are self-limiting, preventable, or not
amenable to treatment. Thus, the expenditure of time
and money in seeking medical attention is frequently
unnecessary or futile for these conditions and results, at
best, only in the offering of some reassurance or com-
fort.


76 Public Health Reports Supplement







Holistic health advocates (who stress the interre-
latedness of mind and body functions) have formed
wellness support groups to encourage each other in
promoting healthy habits.

Self-care groups have also been formed by patients
and their families with particular diseases-for exam-
ple, lupus, diabetes, leukemia, asthma, and others-as
a way of involving patients in recovery or coping with
chronic conditions; with some professional guidance,
group members provide information and emotional sup-
port to each other.
Kronenfeld (24) points out that undue expectations
for self-care can result in "blaming the victim" (for
poor health status), and may relieve social pressure for
more or better health services.

Women's alternative health care. While there may be
conflicting interpretations of whether self-care is a con-
sumer-initiated or provider-initiated concept, there is
no confusion regarding the origins of women's alternate
health care systems. In the 1960s, many women (par-
ticularly young women) became sensitized to what they
perceived as a lack of appropriate health services for
women. The absence of provider sensitivity to women's
health needs is often observed, but it is rarely studied
or systematically documented in statistical terms. One
of only a few exceptions is a study (25), conducted in
San Diego, in which researchers found that physicians
examining husbands and wives who presented with the
same symptoms and complaints gave the husbands more
extensive workups than they did the wives.
Women's health activists engaged in two major ef-
forts in response to perceptions of an inadequate and
insensitive health care system: efforts to pressure the
"establishment" into more appropriate care (exerting
public pressure for stronger controls on experimentation
in contraceptive development, for example, or for in-
formed consent for sterilization, better dissemination
of information on medication to patients, and so on)
and efforts to create an alternate network of health
care services.
In 1971, feminists in Los Angeles developed a "self-
help clinic" program which soon became known na-
tionally. With the help of a plastic speculum, flashlight
and mirror, women help each other to observe their
vagina and cervix, thereby removing some of the "mys-
tery" from those parts of their bodies.
A direct result of these first self-help groups was the
establishment of feminist women's health centers. To-
day, there are approximately 26 women-controlled,
women-operated centers. Emphasis is placed on well-
woman care, providing a variety of services such as Pap
smears, prenatal classes, and first-trimester abortions.


Whether women take on the role of providers them-
selves or attempt to influence the existing health care
system, the question of sensitivity in delivering care is
of paramount importance. The women's movement, by
encouraging women to be better health consumers,
hopes to alter provider behavior as well (8) :

If the patient is generally informed, knows what to expect and
is thus not afraid of the unknown, is not ashamed of her body,
is confident in requesting the information and services she
wants, is aware of her right to request further explanation or
a second opinion, to refuse part or all of a proposed diagnos-
tic or treatment regimen, or to discharge one physician and
engage another, then the physician's role changes too.
Projects using "patient-instructors" for teaching med-
ical students to perform pelvic examinations have been
initiated by the American Medical Students Association
in cooperation with feminist women's health centers.
Experienced physicians explain in detail to the model
patient as they perform a pelvic examination; this
woman then serves as a patient-instructor for medical
students, guiding them both with regard to accuracy
("no, you're not touching my ovaries") and sensitivity
("that hurts").

Women as "family health care providers." Women have
traditionally provided direct nursing care to family
members, have acted as the person primarily responsi-
ble for health promotion within the family, and have
acted as intermediaries by taking family members to
professional health care providers (26) :
Women are the principal brokers or arrangers of health serv-
ices for their children and spouses. The assignment of family
health responsibilities to the female in her role as wife, mother,
or adult daughter, is deeply rooted in cultural norms. These
activities are seen as an integral part of the maternal and
nurturant role women are expected to assume within the
family structure. It is clear that assumptions and predictions
about the role of women as homemakers must take account of
profound social changes that are affecting traditional family
roles. The sharp increase in labor force participation by mar-
ried women, particularly mothers of pre-school and school-age
children, and the rise in the proportion of families headed by
a female must affect the time input to household production
as well as the mix of services produced. The response of social
institutions, including the health care system, to changing
family roles has been uneven and inadequate. As a conse-
quence, the typical employed mother finds herself torn between
the organized and relatively predictable demands of her labor
market role and the unpredictable and time-consuming de-
mands of her more traditional family role.
Naierman and associates noted (6) :

The critical role played by women as extra-market providers
of home health care services for children, the aged, or
chronically ill spouses has seldom been incorporated into
analyses of health resource allocation and utilization. The in-
creasing participation of women in the workforce, combined
with changes in family composition, will inevitably affect the
time and willingness of many women to perform such services.
Substitute resources for the care of the chronically ill and dis-
abled family members may need to be developed.


September-October 1980 77








References
1. Reeves, L., Office of Equal Employment Opportunity,
Public Health Service: Work force by grade and sex,
JAnuary 1974-June 1979. Mimeographed tables, January
1980.

2. Interim report of the Graduate Medical Education Na-
tional Advisory Committee to the Secretary, Department
of Health, Education, and Welfare, DHEW Publication
No. (HRA) 79-633, Health Resources Administration,
April 1979.

3. Bui Dang Ha Doan: Women in health professions. WHO
Statistics Q 32: 154-171 (1979).

4. Minorities and women in the health fields. Applicants,
students, and workers. DHEW Publication No. (HRA)
79-22, Health Resources Administration, October 1978.

5. Witte, H. M., Arem, A., and Holquin, M.: Women
physicians in the United States medical schools: a pre-
liminary report. J Am Women's Med Assoc 31: 211-213
(1976).

6. Naierman, N., Wolcott, I., and Chase, H.: The Health
Resources Administration impact on women: an assess-
ment of HRA authorities and programs as they relate to
women and health. Final report on contract No. 232-
78-0183, Health Resources Administration, Hyattsville,
Md., 1979.

7. Health womenpower: attaining greater influence of
women in the health care system. Report of a regional
conference. DHEW Publication No. (HRA) 79-623,
Health Resources Administration, 1979.

8. Rooks, J. P.: The women's movement and its effect on
women's health care. Ch. 1. In Current obstetrics and
gynecological nursing, edited by L. McNall. C. V. Mosby
Co., St. Louis, Mo., 1980, pp. 3-26.

9. Medicare: health insurance for the aged and disabled,
1976. Summary. Office of Research, Demonstrations, and
Statistics, U.S. Health Care Financing Administration.
In press.

10. Rooks, J. P.: Family planning. Draft Working Papers on
Preventing Disease, Promoting Health for a conference
held in Atlanta, Ga., June 1979. Office of Health Infor-
mation, Health Promotion, and Physical Fitness and
Sports Medicine, Department of Health, Education, and
Welfare.

11. Burris, C.: Women's Lobby statement before the Sub-
commitee on Health and Scientific Research, Senate
Labor and Human Resources Committee, October 1978.

12. Seims, S.: Abortion availability in the United States.
Fam Plann Perspect 12: 88-101, March-April 1980.


13. Abortions and the poor. Alan Guttmacher Institute, New
York, 1979.

14. Gager, N., and Schurr, C.: Sexual assault: confronting
rape in America. Grosset and Dunlap, New York, 1976.

15. Naierman, N.: Sex discrimination in health and human
development. Final report of contract No. HEW 100-18-
0137, June 1979.

16. Healthy people. The Surgeon General's report on health
promotion and disease prevention. DHEW Publication
No. (PHS) 79-55071. Office of the Assistant Secretary
for Health and Surgeon General, Washington, D.C.,
1979.

17. Clark, R., and Barron, D. D.: The General Mills Ameri-
can family report, 1978-1979: family health in an era
of stress. General Mills, Minneapolis, Minn., 1979.

18. It's a fact. Women's Varsity Sports 1: 4, December 1979.

19. Intercollegiate athletics. Sex discrimination. Federal
Register 44: 71314-71423 (No. 23), Dec. 11, 1979.

20. Sprint. National Clearinghouse of Information of Sex
Equity in Sport, January 1980.

21. Physical fitness and exercise. Draft Working Papers on
Preventing Disease, Promoting Health, for a conference
held in Atlanta, Ga., June 1979. Office of Health Infor-
mation, Health Promotion, and Physical Fitness and
Sports Medicine, Department of Health, Education, and
Welfare.

22. National Center for Health Statistics, National Center for
Health Services Research: Health United States 1979.
DHEW Publication No. (PHS) 80-1232, Hyattsville,
Md., 1980.

23. Report of the Task Force on the Evidence Relating to
Dietary Factors to the Nation's Health. Proceedings of a
symposium held in Washington, D.C., May 1979. Ameri-
can Society for Clinical Nutrition, Bethesda, Md., May
1979.

24. Kronenfeld, J.: Self care as a panacea for the ills of the
health care system: an assessment. Social Sci Med 13A:
263-267 (1979).

25. Armitage, K.: Schneiderman, L., and Bass, R.: Response
of physicians to medical complaints in men and women.
JAMA 241: 2186-2187, May 18, 1979.

26. Carpenter, E., Ousterhout, P., and Perry, B.: Women's
role in extramarket health services. Department of Health
Planning and Administration, School of Public Health,
University of Michigan, Ann Arbor, October 1976.


78 Public Health Reports Supplement









Chapter 7. Special Concerns


The United States has long been a nation of unusual
cultural, linguistic, and racial diversity. Within our
country, many minority groups have had special health
problems, some of which are shared by men and women
within the group and others which are unique to
women. Health problems which are shared by all
women, regardless of majority or minority status, have
been the primary focus of the previous chapters of this
report. Throughout the report, however, there have
been references to disparities among subgroups within
the population, most often racial differences in health
indicators, and these will not be repeated here. The
purpose of this section is to highlight those issues in
which gender intersects with race, linguistic group,
age, place of residence, disability, or sexual preference.
Other reports deal with health issues that concern the
problems that men and women share when they are a
racial or linguistic minority, the problems of aging, and
the difficulties of health care delivery in rural settings;
this section does not attempt to review and summarize
these more general studies but focuses on the unique
problems of rural, older, minority, disabled, and homo-
sexual women.
The paragraphs that follow are not comprehensive
reviews of the health problems encountered by each
group. Some of these problems have been noted earlier


in this report. For others, data are lacking or of poor
quality. Subsequent paragraphs only highlight some
examples of special concerns.

Disabled Women
Although statistics on disabled persons are sparse, it
is estimated that about 5 million women are disabled.
Many of the barriers that disabled women confront are
also problems for men. However, they also face some
particular difficulties, especially in regard to employ-
ment and reproduction.
The Rehabilitation Services Administration (RSA)
in the Office of Human Development, DHHS, supports
services which improve conditions and otherwise benefit
disabled individuals, with emphasis on the severely
disabled, including the developmentally disabled. Sur-
veys conducted by RSA at Federal, State, and local
levels have shown limited opportunities for disabled
females. For example, in 1976 women tended to be
older at the time of referral (34 years of age as against
30.7 years for men). Fewer women than men who were
rehabilitated were in wage-earning occupations; in
1976, 68.5 percent of rehabilitated women were in such
occupations compared to 93.7 percent of rehabilitated
men; in 1977 the figures were 70.4 percent and 94.2
percent, respectively.


September-October 1980 79







DHHS has issued regulations in connection with the
Vocational Rehabilitation Act of 1973 (Public Law
93-112) prohibiting any program or activity which
receives Federal financial assistance from discriminating
against disabled persons solely on the basis of the dis-
ability. The regulations apply to anyone who has a
physical, mental, or sensory impairment which severely
limits one or more major life activities-for example
walking, seeing, or hearing.
More attention is being given to educating health
care providers on the reproductive needs of disabled
women. For instance, many nurses and physicians seem
to have assumed that disabled persons were either not
sexually active or not fertile, and thus had no need for
family planning. The Task Force on Concerns of Phys-
ically Disabled Women has compiled two booklets-
"Within Reach," which was written for family planning
providers and which gives explicit information on how
to make a facility barrier-free, and information on birth
control and sexuality as it affects physically disabled
women. The other Task Force booklet is for physically
disabled women themselves and deals with body image,
relationships, and special physical concerns.
The needs of the disabled are currently given par-
ticular attention at many conferences; for example,
hotels and conference facilities are checked for access
before being selected as a conference site. Research
needs are also receiving attention, such as the need to
develop an external urinary device for women with
neurological bladder problems (1).

Older Women
Women's advantage in longer life expectancy means
that the problems of old age are, to a great extent,
problems of women. Women 65 and older are also the
fastest-growing segment of the U.S. population. Be-
tween 1960 and 1970, the number of such women
increased by 41 percent. In 1950, there were approxi-
mately equal numbers of older men and women in the
United States but, by mid-1977, census estimates placed
the number of older women at 13.9 million compared
to 9.5 million older men. Predictions for the year 2035
are 33.4 million older women and 22.4 million older
men (2). Nearly two-thirds of women over 65 are
widows, many of whom live in relative social isolation
and with diminished financial resources.
Older men and women share many health needs
including availability of good medical and nursing care,
appropriate use of medication, availability of good
nutrition, opportunity for exercise, and a safe environ-
ment. However, women's longevity puts them at greater
risk of disease. Women have higher rates of many
chronic conditions that do not cause early death, but


which limit the way a person lives. Men have higher
rates of fatal illnesses.
Arthritis, hypertension, diabetes, visual impairment,
mental and nervous conditions, hearing impairments,
and asthma are more common among older women
than men. Because of osteoporosis, a condition in which
the bones become thin, brittle, and vulnerable to frac-
tures, women are about three to five times as likely as
men to have impairment of their hips, backs, and
spines.
Only 5 percent of the population of older men and
women reside in nursing homes at any one time. Of
the total number of nursing home residents in 1977, 74
percent were female-927,800 female, 375,300 male
residents (3). Institutionalization rates differ between
men and women because older women have longer life
expectancies, have more health problems limiting their
ability to be independent, are more economically im-
poverished, and have fewer caretakers and social sup-
ports (4).
Most medical care for older, poor women is provided
through mechanisms such as Medicare, which enables
treatment of the chronic conditions of aging but pro-
vides no preventive, self-care programs. This lack pro-
motes perpetuation of feelings of ill health in older,
poor women, since they can receive attention and care
only in the context of illness. Because of the serious

concern with the costs of long-term care, and with many
Americans' lack of access to chronic care (many are
institutionalized unnecessarily because of inadequate
community- or home-based alternatives or because of
income ineligibility for noninstitutional services), Con-
gress appropriated $20.5 million for fiscal year 1980
for "channeling demonstration programs" to be con-
ducted in a variety of locations and under a variety of
auspices. At least 75 percent of the participants are to
be elderly persons (the remainder are to be functionally
disabled adults). "Channeling" includes formal assess-
ment of individual needs, formal referral to agencies
with which there is a negotiated agreement, and stand-
ardized recordkeeping and followup procedures. Ex-
perience with variations in reimbursement mechanisms
is expected to result in legislative recommendations.
Different types and options of health care delivery
are needed to enable older persons to receive care
within their own communities, thereby allowing them
to retain autonomy and independence.
The National Institute on Aging (NIA) was estab-
lished in 1974 to conduct and support social, biomedi-
cal, and behavioral research and training related to
the aging process. Research on older women has been
the focus of several conferences and grants supported
by NIA.


80 Public Health Reports Supplement







The National Institute on Aging and the National
Institute of Mental Health sponsored a 3-day workshop
on "The Older Woman: Continuities and Discontinui-
ties" in 1978 (2). Its purpose was to stimulate the
interest of behavioral and social scientists in research
questions concerning older women and to identify areas
where research is needed.
The current Director of NIA has described with
candor one of the problems women encounter as health
care consumers (5):

Older women can not count on the medical profession. Few
doctors are interested in them. Their physical and emotional
discomforts are often characterized as post-menopausal syn-
drome, until they have lived too long for this to be an even
faintly reasonable diagnosis. After that they are assigned the
category of senility.

Although a majority of older persons are female,
much research on aging has included only men as
subjects. For example, a 20-year ongoing longitudinal
study conducted by the Gerontology Research Center in
Baltimore did not include women as subjects until 1978.
In preparation for anticipated health needs of the
U.S. population, resources for the promotion of geri-
atric training for health providers are increasing. For
instance, in 1979 Congress authorized the Bureau of
Health Manpower, HRA, to provide $2 million for
training in clinical geriatrics. Grants may be awarded
to programs which prepare a variety of health profes-
sionals, including allied health professionals and nurses.

Rural Women
It is difficult to obtain health data by both sex and
urban-rural residence. Rural women and men share
the difficulties of sparse health services and isolation,
but women are often less mobile and even more isolated
than men. Consolidation of hospitals and other health
services has, in some cases, reduced farm women's access
to care. The anonymity that urban centers provide,
which may be important to serve women seeking family
planning and abortion services, is often absent in a rural
community.
Infant mortality, an often-used barometer of general
levels of health status, ranged in 1976 from 12.9 deaths
per 1,000 live births for white infants born in metro-
politan areas to 25.4 for nonwhite infants in nonmetro-
politan areas (table 28, page 62), and Ahearn, Mary,
U.S. Department of Agriculture, unpublished paper on
child health, 1979).
Provider availability is an acute problem in rural
areas. While there were 48 obstetrician-gynecologists
per 100,000 women of childbearing age in 1973 in
metropolitan areas, there were only 18 in nonmetro-
politan areas (6).


Figure 38. Proportion of women with unmet needs for abortion
services, by selected characteristics, fiscal year 1977


Percent of unmet need

64


9



Medi
eligib


26
23




t ...


caid- Nonmetro-
le politan


14




Nonwhite
Nonwhite


31


21






Teenage
(15-19)


SOURCE: Abortions and the poor. Alan Guttmacher Institute, New York, 1979.
According to Kleinman and Wilson (7) "Medically
underserved residents receive less preventive and pre-
natal care than any other services in comparison with
residents in adequately served areas" (table 24, page
56).
Efforts are continuing to increase the availability of
family planning services, including those in rural areas.
The differential in access to abortion services is particu-
larly striking with regard to rural women (fig. 38),
many of whom either do not obtain the service or must
travel great distances to do so (8).

Lesbian Women
Homosexual women have most of the same health needs
as heterosexual women. There are, however, several
special obstacles facing homosexual women seeking
quality health care.
The assumption is often made by health care pro-
viders that the client is heterosexual and that female
health needs necessarily include contraception. Some
lesbians, afraid of negative reactions to disclosure of
their homosexuality, avoid encounters with the medical
system.
The assumption is also often made that lesbians will
not become parents. Some lesbian women who elect to
have children fear hostility during pre- and post-natal
care.


September-October 1980 81


*







Hospital guidelines and health insurance do not rec-
ognize homosexual partners as "close family." In emer-
gency situations, partners do not have the power to
sign legal consent forms, or visitation rights in hospital
intensive care units.

Racial and Ethnic Minorities
Availability of data and classification present problems.
Some data are available only for white compared with
black (the largest racial minority). Other data com-
pare whites with "all others" or nonwhites, thus in-
cluding Asian Americans, Pacific Islanders, Native
Americans (Indians, Aleuts, and Eskimos), and some-
times Hispanics. There are various ways to categorize
"Hispanics," "persons of Spanish origin," and "persons
with Spanish surname." Difficulties in classification of
minority group individuals results in separating groups
that have problems in common, and in grouping to-
gether persons who have vastly different health needs.
Both black and white males have higher mortality
rates than females of both races-that is, gender is a
greater factor than race in overall risk of mortality.
However, maternal mortality among blacks is three
times that of whites; the maternal mortality rate among
Indians is actually lower than rates for whites, down
significantly since 1958 when it was more than double
the U.S. rate (9). Black infant mortality is nearly dou-
ble that of whites; Chinese- and Japanese-Americans
have the lowest infant mortality rates (9). Age-adjusted
cancer mortality rates are higher for nonwhite than
for white females. The American Cancer Society and
the Roswell Park Memorial Institute held an inter-
disciplinary conference on cancer in black populations
throughout the world in May 1980.
In 1978, 11 percent of U.S. households with children
were headed by women-a 50 percent increase since
1970. Many of these households are poor; the median
income for such households was only 44 percent that of
households with married couples. While 9 percent of
white households with children were female-headed,
this figure was 17 percent among those with "Spanish
surname" and 35 percent among blacks.
Although the incidence of tuberculosis has greatly
declined among Native Americans, it is still higher than
among other racial groups. There is some evidence that
cervical cancer may be increasing among Native Amer-
ican women. Since the 1920s, Native Americans who
live on reservations have been on "commodity diets"-
that is, they receive food rather than food stamps with
which to choose their foods. This may add to a genetic
predisposition to obesity and to diabetes among Ameri-
can Indians.
Women who do not speak English fluently have
special difficulties negotiating the health care system,


from finding appropriate care to obtaining third-party
payments. When a woman is sick, the likelihood of
frustration and confusion in obtaining information and
services can be exacerbated. Many foreign-born women
have the additional problem of isolation. Questions of
embarrassment and modesty make visits to a male
gynecologist or a family planning center particularly
difficult for some.
Newly arrived immigrants face a host of practical
and psychological problems in adjusting to their new
country. Immigrant women, often faced with crowded
home environments, dual (sex and race) discrimination
in obtaining work, and isolation in the home, must meet
formidable challenges in attending to their own and
their family's health needs.
Breast cancer rates of Asian American women are
higher than those of Asian women in their native coun-
tries and approach those of American women.
When asked in 1978 to rate their own overall health
and "well-being" in the ongoing national Health Inter-
view Survey, black females reported the lowest level
of positive well-being of all categories: 37 percent com-
pared with 70 percent among white males.
The problems just touched on are merely examples
of many group-specific problems encountered by certain
categories of women. More data are needed to under-
stand these and other health problems more fully.

References
1. Brown, J. W., and Redden, M. R.: A research agenda on
science and technology for the handicapped. American
Association for the Advancement of Science, Washington,
D.C., 1979.
2. National Institute on Aging: The older woman: continui-
ties and discontinuities. Report of the National Institute on
Aging and the National Institute of Mental Health Work-
shop, September 14-16, 1978. DHEW Publication No.
(NIH) 79-1897, Bethesda, Md., October 1979.
3. National Center for Health Statistics: The National Nurs-
ing Home Survey: 1977 summary for the United States.
Vital and Health Statistics, Series 13, No. 43, DHEW
Publication No. (PHS) 79-1794. Hyattsville, Md., 1979.
4. Mylander, M.: News and notes. Summary of conference
on older women-continuities and discontinuities, Septem-
ber 14-16, 1978. Women and Health 4:3, fall 1979.
5. Butler, R., and Lewis, M.: Aging and mental health. C. V.
Mosby Co., St. Louis, 1977.
6. Comparative statistics on health facilities and population:
metropolitan and nonmetropolitan areas. American Hospi-
tal Association, Chicago, Ill., 1978.
7. Kleinman, J. C., and Wilson, R. W.: Are medically under-
served areas medically underserved? Health Serv Res 12:
147-162, summer 1977.
8. Abortions and the poor. Alan Guttmacher Institute, New
York, 1979.
9. National Center for Health Statistics, National Center for
Health Services Research: Health United States 1979.
DHEW Publication No. (PHS) 80-1232, Hyattsville, Md.,
1980.


82 Public Health Reports Supplement









Chapter 8. Data and Research Needs


Delegates to the First National Women's Conference in
Houston in 1977 recommended that data based on
standard definitions be collected on beneficiaries of all
Federal programs by sex, minority status, and by urban-
rural or metropolitan-nonmetropolitan areas. That ac-
cess to such data still constitutes a problem is evidenced,
for example, by reports on rural health care that do not
include any tables by sex. In a report to the Health
Resources Administration, Naierman and associates
noted (1) : "Gender categories are often absent from
health planning data. If health plans are to reflect
women's health needs, it is critical that women's health
status and service utilization be distinguished from
men's."
In many instances, the presentation of data for all
persons age 65 and above conceals important distinc-
tions-related to health problems and services-among
older people, the majority of whom are women. That
is, people 65-75 have quite different health needs from
those of the "frail elderly" ages 75 and above.
Many data are actually collected by sex but are not
published in that form.
Often data are presented by a single variable. It
would add to the understanding of health and health
system needs if sex were to be analyzed more frequently
along with other variables such as marital status, age,


education, and occupation. To understand why wom-
en's work loss rates are consistently higher than men's,
it would be useful to relate these variables to personal
and family illness, injury, child care, and sick leave
provisions.
Economist Charlotte Muller urges that women's
multiple roles be taken into account when assessing
health data needs, and suggests that data on personal
work and health history be collected as well as current
health status, to provide valuable information to assess
current needs for services at both the individual and
aggregate level (2) :
Contemporary data on women's health should take into ac-
count roles and role changes. Most current statistical systems
are set within a conceptual framework that was developed
during a period when acceptable roles for women were cen-
tered around household functions and when the participation
of women in a variety of activities tended to be restricted in
authority and scope. Therefore, the objectives, classifications,
and data collection methods of the health data system reflected
certain norms and assumptions that are less and less appro-
priate to current needs. ...
Role responsibilities in relation to child care, economic ac-
tivity, and management of illness are affected by the rise in
households with women as the sole adult ....
When roles are not clearly perceived, analytic categories
used in research can be questioned. For example, Berry and
Boland (3), in estimating economic consequences of alcohol
abuse, assume that the major impact of women's alcoholism
will be on nonmarket activities ...


September-October 1980 83







Aside from the general impacts of life-style and life events
on health, household roles have a particular configuration so
far as women are concerned. That is, their investment of time
is divided between their own health capital and that of other
members of the household, and even other households when
already elderly parents become "health dependents"....
Not enough is known about the conduct of these activities,
the division of tasks between the spouses, the resources avail-
able, the knowledge base used, and types of decisions made.
If adequate information were collected, it could be analyzed
in conjunction with statistics on the amount and quality of
health maintenance activities, use of market services, health
status achieved, and satisfaction with the process and its re-
sults. Such data could be used to improve the efficiency of
households through social investment in supportive services,
including adaptation of health care systems to role shifts, task
overloads. ...
Histories should be collected and classified, and current
health of women should be classified according to personal
history. To do this, concepts of employment and occupation
should be adapted to express (a) labor force participation
interrupted by homemaker service, (b) part-time employment
(part-day, part-week, and part-year), and (c) extensive vol-
unteer service with and without fixed daily hours. Role com-
binations should be identified ....
For individuals, their history and current status with ref-
erence to general health, reproduction, personal roles, number
of health care sources, and insurance status should be deter-
mined. Number of care sources is important for women be-
cause a portion of primary care is received either in connection
with fertility or from sources used for fertility management,
as well as from general medicine providers ....
In considering access to care, privacy concern [should be]
included in the list of barriers to care....

Many research studies use only male subjects; data
often cannot be validly generalized to the female popu-
lation. For example, epidemiologic studies of work haz-
ards have focused on male workers. Only 3 of 374
recently completed studies on alcoholism focused on
women.
Participants in a recent panel discussion on the role
of stress concluded (4) :

Possible stress implications in human female reproductive
dysfunction [infertility, amenorrhea, menstrual and premen-
strual distress, nausea of pregnancy, postpartum difficulties,
etc.] remain almost totally unexplored. Although studies of the
effect of endocrine function on psychological functioning are
familiar, there has been little effort to investigate a possible
reverse influence.

Research is needed on senility and osteoporosis.
Marieskind (5) stresses the critical need for data on
the effects on women and infants of technologies such
as electronic fetal monitoring and Cesarean section, as
a basis for resolving the current dispute over use of
these techniques.
Estelle Ramey of the President's Advisory Committee
for Women urges further research on premenstrual
tension and dysmenorrhea. Often dismissed as psycho-
somatic, it can be debilitating for a small minority of
women.
Many women and family planning providers hope
for increased research to develop safer effective contra-


84 Public Health Reports Supplement


ceptives for both women and men. A January 1980
announcement by the NIH's Center for Population
Research offers hope that brain hormones may provide
the basis for an entirely new, and safer, form of sys-
temic contraception for both females and males.

The President's Advisory Committee for Women
(unpublished document, 1979) recommended that:

When discussing the differences in female versus male mor-
tality, an emphasis should be placed on determining the
physical factors which contribute to the improved health of
women in order for preventive measures to be applied to men's
health. This is important because as women increasingly out-
live men, the older women are frequently being left alone.
Their health and quality of life can be improved if that of
men is improved (and the men live longer).

The Task Panel on Women and Mental Health, of
the President's Commission on Mental Health, con-
cluded that (6) :

Crosscutting all areas for research are concern with life
cycle perspective, concern about all marital, socioeconomic,
ethnic, and racial groups. Although further research is needed
on women of all ages, emphasis should be placed on those
stages that have been understudied: early adolescence, young
adults, women in midlife, and the elderly.
It is crucial that all new research be designed, conducted,
and staffed with an awareness of potential sex bias in existing
theory, methodology, instrumentation, and interpretation.

The Health Planning Act mandates "a study of al-
ternative settings in which health services can best be
provided. The growing use of alternative health facili-
ties, such as women's health centers and family-oriented
childbirth centers, are not considered in assessments of
availability and appropriateness of health services" (1).

References
I. Naierman, N., Wolcott, I., and Chase, H.: The Health
Resources Administration: impact on women: an assess-
ment of HRA authorities and programs as they relate to
women and health. Final report on contract No. 232-78-
0183, Health Resources Administration, Hyattsville, Md.,
1979.
2. Muller, C.: Women and health statistics: areas of deficient
data collection and integration. Women and Health 4:
37-59, spring 1979.
3. Berry, R. E., Jr., and Boland, J. P.: The economic costs
of alcohol abuse. MacMillan Company, New York, 1977.
4. The role of stress in female reproductive dysfunction. Sum-
mary of a panel discussion. J Hum Stress, June 1979, pp.
38-45.
5. Marieskind, H. I.: An evaluation of cesarean section in
the United States: Final report submitted to the Depart-
ment of Health, Education, and Welfare, Office of Assist-
ant Secretary for Planning and Evaluation/Health, Wash-
ington, D.C., June 1979.
6. Lazar, J.: Research recommendations from the report of
the Task Panel on Women and Mental Health, President's
Commission on Mental Health. Reprinted in News and
Notes, Women and Health 4: 111-116, spring 1979.


A U.S. GOVERNMENT PRINTING OFFICE: 1980 0- 311-242'51








Abbreviations Used in This Report


AAMC Association of American Medical Colleges
AASECT American Association of Sex Educators,
Counselors, and Therapists
ADAMHA Alcohol, Drug Abuse, and Mental Health
Administration
AID Agency for International Development
ASCN American Society for Clinical Nutrition

BCDDP Breast Cancer Detection Demonstration
Project

CDC Center for Disease Control
CHD Coronary heart disease
CNMs Certified nurse-midwives
COSH Committee on Occupational Safety and
Health
CPR Center for Population Research
CPSC Consumer Product Safety Commission

DAWN Drug Abuse Warning Network
DBCP Dibromochloropropane
D & C Dilation and curettage
D & E Dilation and evacuation
DES Diethylstilbestrol
DHEW Department of Health, Education, and
Welfare
DHHS Department of Health and Human Serv-
ices

EAB Ethics Advisory Board
EFM Electronic fetal monitoring

FDA Food and Drug Administration

GWB General well-being

HANES Health and Nutrition Examination Survey
HEW see DHEW
HIS Health Interview Survey


HRA
HSA

IUD


Health Resources Administration
Health Services Administration

Intra-uterine (contraceptive) device


MIC Maternal and infant care
MOAR Men Organized Against Rape


NCHS National Center for Health Statistics
NCI National Cancer Institute
NHI National Health Insurance
NIA National Institute on Aging
NIAAA National Institute of Alcohol Abuse and
Alcoholism
NICHHD National Institute of Child Health and
Human Development
NIDA National Institute on Drug Abuse
NIH National Institutes of Health
NIOSH National Institute for Occupational Safety
and Health
NSFG National Survey of Family Growth


OPA
OSHA

OTC
PHS
PID
PPI
RSA


Office of Population Affairs
Occupational Safety and Health Adminis-
tration
Over-the-counter
Public Health Service
Pelvic inflammatory disease
Patient package insert
Rehabilitation Services Administration


SEER Surveillance, Epidemiology, and End Re-
sults Report
SIECUS Sex Information and Education Council
for the United States
STD Sexually transmitted diseases


Women, infants, and children


WIC








U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Health Resources Administration
Rm. 10-44, Center Bldg.
3700 East-West Highway
Hyattsville, Md. 20782


POSTAGE AND FEES PAID
U.S. DEPARTMENT OF HHS
HHS-396

CONTROLLED CIRCULATION RATE
PUBLIC HEALTH REPORTS
(USPS 324-990)


OFFICIAL BUSINESS
PENALTY FOR PRIVATE USE, $300


HRA-80-605




University of Florida Home Page
© 2004 - 2010 University of Florida George A. Smathers Libraries.
All rights reserved.

Acceptable Use, Copyright, and Disclaimer Statement
Last updated October 10, 2010 - - mvs