The social determinants of health are the circumstances in which people are born, grow up, live, work, and age and the systems put in place to deal with illness. These circumstances, in turn, are shaped by a wider set of forces: economics, social policies, and politics. Reproductive health indicators and conditions that are germane to obstetricians and gynecologists vary across states and regions in the United States as well as within regions and states. The aim of this article is to illustrate this variation with the use of examples of gynecologic malignancies, sexually transmitted infections, teen birth rates, preterm birth rates, and infant mortality rates. Using the example of infant death, the difficulties in “unpacking” the construct of place will be discussed, and a special emphasis is placed on the interaction of race, place, and disparities in shaping perinatal outcomes. Finally, readily available and easy-to-use online data resources will be provided so that obstetricians and gynecologists will be able to assess geographic variation in health indicators and outcomes in their own localities.
The Institute of Medicine has adopted the definition of population health proposed by Stoddart and Kindig as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” Implicit in this definition is the understanding that health outcomes at the population level are determined by multiple individual and societal factors. What is measured as population health outcomes is ultimately determined by individual decisions about one’s health, interactions with health care, and the larger social and geopolitical environment across populations. Hence, one defining characteristic of a population is place. Because characteristics of place vary, it stands to reason that health outcomes and indicators of populations will vary.
Geography has been defined as “the study of what is where, why there, and why care?” The definition incorporates the phenomenologic “what” to include features that occur in spatial distribution (natural and cultural); the spatial where incorporates elements of location; the analytic why there encompasses processes and interrelationships, and the implicational why care accounts for relevance. The definition is at once descriptive and conceptual and incorporates the complex context of what we consider as place. This definition provides a framework for those who are involved in the enterprise of caring for individuals in health care settings to better understand the individual and the population being served.
It is not surprising that the circumstances that people grow up and live in (an aspect of what we call geography) have implications for their health. As posited by Frieden who used the construct of a 5-tiered pyramid that depicts the impact of interventions to effect change in health outcomes, changing the socioeconomic factors and the contexts in which people grow and live is likely to have the greatest ability to effect change. Disparities in health outcomes have been well-described. However, quietly accepting that disparities are immutable will guarantee only that they persist. For the obstetrician-gynecologist, understanding the variation in women’s and perinatal health indicators and outcomes for populations is a necessary first step in moving toward elimination of disparities, which is one of the overarching goals of the US Department of Health and Human Services’ Healthy People 2020 . Hence, the aim of this article is to show geographic variation in selected health indicators and outcomes that are pertinent to the specific interests of obstetricians and gynecologists by using readily available public data. Most important, the article will provide interactive resources that are updated consistently so that readers can access the information that is most important to them and the women they serve.
Examples of geographic variation in outcomes and indicators for obstetricians and gynecologists
Table 1 shows examples of variation in several outcomes and indicators that are pertinent to the work of obstetricians and gynecologists. Although there are degrees of variation among states for different conditions and indicators, it is also important to note that health varies even within states. For example, although almost all counties in New Mexico (a state with high teen birth rates) have teen birth rates higher than almost all counties in New Hampshire (a state with low teen birth rates), there is some overlap of county level rates, and in each state, there are county pockets with low and high rates relative to other counties. Similarly, states with relatively high rates of gonorrhea and/or syphilis have counties with rates as low as the lowest overall state rates. States with the highest breast cancer incidences do not necessarily have the highest death rates, as would be expected for a disease incidence highly dependent on screening access and practices. Ovarian cancer, with its relatively high case fatality rate, has less difference between incidence and death rates. This can be seen in a more graphic fashion by accessing the Centers for Disease Control and Prevention’s interactive cancer atlas. Such variation between and within states suggests a level of complexity of geography and points to the importance of understanding that context on the local level when caring for women as members of a population.
| State | Breast cancer a | Ovarian cancer a | Gonorrhea rate for 2012 b | Primary and secondary syphilis rate for 2012 b | Teen birth rate for 2012 c | Infant mortality rate for 2010 d | ||
|---|---|---|---|---|---|---|---|---|
| Incidence | Death rate | Incidence | Death rate | |||||
| Alabama | 116.2 | 23.5 | 11.3 | 8.8 | 193 | 4.5 | 39.2 | 8.73 |
| Alaska | 124.5 | 21.8 | 10.2 | 5.2 | 101 | 1.5 | 34.5 | 3.57 |
| Arizona | 108.3 | 19.4 | 11.6 | 7.6 | 90 | 3.1 | 37.4 | 5.94 |
| Arkansas | — | 22.7 | — | 7.5 | 146 | 5.9 | 45.7 | 7.24 |
| California | 117.9 | 20.7 | 11.7 | 7.7 | 89 | 7.8 | 26.5 | 4.74 |
| Colorado | 124.0 | 20.0 | 11.7 | 9.3 | 55 | 4.1 | 25.4 | 5.91 |
| Connecticut | 138.5 | 20.9 | 13.0 | 7.4 | 60 | 1.5 | 15.1 | 5.30 |
| Delaware | 130.9 | 22.7 | 8.2 | 7.1 | 99 | 4.2 | 25.0 | 7.48 |
| District of Columbia | 142.9 | 30.4 | 8.1 | 6.2 | 389 | 26.7 | 38.6 | 7.64 |
| Florida | 111.2 | 21.3 | 11.4 | 6.9 | 102 | 7.2 | 28.0 | 6.51 |
| Georgia | 117.2 | 23.6 | 11.7 | 8.4 | 156 | 9.5 | 33.8 | 6.34 |
| Hawaii | 130.7 | 14.8 | 10.0 | 7.0 | 59 | 1.7 | 28.1 | 6.21 |
| Idaho | 116.9 | 21.3 | 11.6 | 5.4 | 11 | 1.6 | 28.3 | 4.78 |
| Illinois | 125.4 | 22.6 | 12.0 | 7.8 | 141 | 6.2 | 27.9 | 6.84 |
| Indiana | 114.0 | 22.8 | 10.4 | 8.4 | 113 | 3.4 | 33.0 | 7.62 |
| Iowa | 126.5 | 19.4 | 12.3 | 8.8 | 66 | 2.3 | 24.1 | 4.86 |
| Kansas | 118.1 | 20.4 | 10.7 | 7.7 | 78 | 0.8 | 34.1 | 6.20 |
| Kentucky | 118.5 | 21.8 | 10.4 | 7.8 | 98 | 3.4 | 41.5 | 6.81 |
| Louisiana | 121.6 | 24.6 | 9.5 | 7.0 | 194 | 7.4 | 43.1 | 7.55 |
| Maine | 125.1 | 20.1 | 10.6 | 9.1 | 34 | 1.3 | 19.4 | 5.40 |
| Maryland | 128.7 | 24.1 | 10.0 | 8.2 | 98 | 7.4 | 22.1 | 6.83 |
| Massachusetts | 125.1 | 19.1 | 10.0 | 7.0 | 40 | 4.8 | 14.1 | 4.39 |
| Michigan | 115.6 | 23.7 | 12.6 | 8.4 | 127 | 3.0 | 26.3 | 7.12 |
| Minnesota | — | 20.1 | — | 7.9 | 58 | 2.2 | 18.5 | 4.55 |
| Mississippi | 112.9 | 24.9 | 8.0 | 6.8 | 231 | 5.0 | 46.1 | 9.62 |
| Missouri | 117.4 | 23.4 | 10.2 | 7.4 | 146 | 2.6 | 32.2 | 6.58 |
| Montana | 128.0 | 21.1 | 11.1 | 8.6 | 11 | 0.2 | 28.8 | 5.97 |
| Nebraska | 116.3 | 19.2 | 10.4 | 7.3 | 78 | 0.4 | 26.8 | 5.25 |
| Nevada | 108.1 | 23.6 | 8.5 | 7.0 | 83 | 5.1 | 33.4 | 5.51 |
| New Hampshire | 127.8 | 21.7 | 10.3 | 7.7 | 11 | 2.7 | 13.8 | 3.88 |
| New Jersey | 124.7 | 23.2 | 13.4 | 8.5 | 85 | 2.6 | 16.7 | 4.80 |
| New Mexico | 106.3 | 22.1 | 10.3 | 7.5 | 90 | 4.9 | 47.5 | 5.60 |
| New York | 123.6 | 21.6 | 12.4 | 7.7 | 116 | 6.3 | 19.7 | 5.08 |
| North Carolina | 125.0 | 23.3 | 11.0 | 7.5 | 148 | 3.6 | 31.8 | 7.09 |
| North Dakota | 121.2 | 22.8 | 11.1 | 6.7 | 49 | 0.6 | 26.5 | 6.81 |
| Ohio | 112.3 | 24.0 | 10.4 | 8.2 | 143 | 3.7 | 29.8 | 7.72 |
| Oklahoma | 119.3 | 24.8 | 10.5 | 8.3 | 117 | 2.2 | 47.3 | 7.49 |
| Oregon | 124.4 | 22.9 | 11.0 | 9.1 | 38 | 5.5 | 23.8 | 4.96 |
| Pennsylvania | 124.7 | 23.3 | 12.9 | 8.2 | 121 | 3.9 | 23.7 | 7.23 |
| Rhode Island | 110.4 | 19.0 | 7.7 | 6.5 | 48 | 4.2 | 19.9 | 7.16 |
| South Carolina | 119.4 | 22.5 | 9.4 | 8.0 | 163 | 4.8 | 36.6 | 7.34 |
| South Dakota | 109.1 | 19.5 | 10.0 | 6.1 | 86 | 2.2 | 33.3 | 7.11 |
| Tennessee | 115.7 | 22.4 | 11.8 | 7.9 | 142 | 4.2 | 38.5 | 7.87 |
| Texas | 109.8 | 20.8 | 10.6 | 7.5 | 127 | 6.3 | 44.4 | 6.15 |
| Utah | 110.7 | 22.2 | 11.9 | 7.9 | 17 | 1.5 | 23.3 | 4.86 |
| Vermont | 131.9 | 19.1 | 14.2 | 8.9 | 16 | 1.0 | 16.3 | 4.18 |
| Virginia | 118.6 | 22.2 | 11.3 | 8.1 | 85 | 3.5 | 22.9 | 6.83 |
| Washington | 129.0 | 20.9 | 13.3 | 8.4 | 47 | 4.4 | 23.4 | 4.48 |
| West Virginia | 111.1 | 20.5 | 12.8 | 7.5 | 49 | 0.4 | 44.1 | 7.33 |
| Wisconsin | 116.9 | 21.3 | 11.9 | 8.0 | 82 | 1.6 | 21.9 | 5.84 |
| Wyoming | 107.4 | 22.3 | 13.1 | 9.3 | 8 | 0.7 | 34.7 | 6.88 |
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