Women’s health is in a “perilous” place with deep and growing inequalities across regions of the US, a new report from the Commonwealth Fund has found. The report ranks states based on 32 indicators, ranging from insurance coverage to breast and cervical cancer to Covid-19.
Massachusetts, Rhode Island and Vermont ranked at the top across a range of health issues. South-eastern states – most of which now have near-total abortion bans – ranked at the bottom on a wide range of women’s health indicators.
“Where you live matters to your health and healthcare,” said Dr Joseph Betancourt, president of the Commonwealth Fund. “This is having a disproportionate effect on women of color and women with low incomes.”
The goal of the report was to contribute to policies, “guaranteeing all women across the US can have access to quality affordable care – no matter where they live”.
The report largely relies on public data from 2022, a pivotal year in women’s health, when the supreme court overturned Roe v Wade. For nearly 50 years, Roe v Wade provided a federal right to terminate a pregnancy. When the decision was overturned, regulation of abortion reverted to the states. Fourteen quickly issued near-total abortion bans, including many across the south-east.
A map of the worst-performing states in the nation looks like a belt across the American south, stretching from Nevada to Florida and north to Tennessee. Notably, Nevada does not have an abortion ban, but tends to have worse health metrics because of a large, first-generation immigrant population.
“There are clear distinctions between states and delivery systems that perform well for women,” said Sara Collins, a vice-president at Commonwealth and senior scholar studying healthcare access and quality.
States that tended to perform worst had not expanded Medicaid, a public health insurance for low-income Americans. They also tended to have fewer healthcare providers overall, particularly OB-GYNs. Those regional differences are likely to be exacerbated by abortion bans, which make it legally perilous for doctors to practice.
Deaths from all causes were highest in south-eastern states – including from preventable causes such as substance use, Covid-19, pregnancy-related deaths and chronic treatable conditions.
Poor performing states also tended to miss opportunities to identify and treat at-risk women. They screened fewer women for postpartum depression, had higher rates of syphilis and congenital syphilis (when the disease is passed to a baby) and higher rates of cancer. They had higher rates of cesarean births for low-risk pregnancies and the worst maternal mortality rates, with particularly stark disparities between Black and white women.
Also notable is how these trends have become more pronounced in the last four decades. In other reports, researchers have found health disparities shrank between the 1960s and 1980s. Now, worse health outcomes in the south form what some researchers call the “multiples” belt, where a laundry list of health outcomes are worse – from cancer to diabetes to HIV infection rates.
Still, the prospects of state legislatures or Congress finding common ground to improve women’s health look dim. Many of the issues most impactful to women’s health are also the most politically contentious.
For instance, Republicans have actively sought abortion bans for decades and opposed the expansion of Medicaid since the Obama administration. Republicans have also undermined public health authorities, the sort of workers who are key to disrupting transmission of diseases such as syphilis.
Some researchers, such as the health equity expert Daniel Dawes, have described these outcomes as the “political determinants of health” – in other words, the ways policy shapes the health and wellbeing of the population.
“When you think of the structural conditions that many folks find themselves in, there is an underlying policy – political action or inaction – that has determined those conditions and structured the resources that has enabled those conditions to exist,” said Dawes, founding dean of the School of Global Health at Meharry Medical College in Nashville, Tennessee.
Without addressing those politics, Dawes said, “you’re only going to continue nibbling around the edges of the problem.”
