Women's Health: An Emerging Definition

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Women's Health: An Emerging Definition

by Tina Shaw

Executive Summary

Introduction

Issues Relevant to Women's Health

State Examples

Federal Efforts to Address Women's Health Conclusion

Acknowledgments

Notes

Executive Summary

Traditionally, women's health was thought to include only issues of childbirth and reproductive health. Increasingly however, it is being seen to encompass a broad range of issues.

Gender-specific medical research has demonstrated major differences between the way male and female physical systems develop and handle disease. Heart disease and stroke, diabetes and depression are just a few examples of medical conditions that affect women and men differently. In addition to physical differences, men and women face different challenges in obtaining and paying for medical services. Economic status, health insurance coverage, and a woman's role as caregiver equally affect a woman's health. The interplay between medical, social, and economic issues alike are critical to understanding the diverse needs of women.

This report presents information about medical and social issues involved. State legislatures have chosen to address women's health in different ways. From establishing an official office of women's health within the state government, to addressing individual issues within existing offices or committees, states are finding various ways to address the issues.

Lastly, the report discusses the federal government's approach to addressing women's health and concludes that state legislators are in a unique position to examine specific needs in their states regarding women's health and to develop effective policies to address those issues at the state level.

Introduction

Jane awoke feeling light-headed, nauseated and short of breath; she feared she had the flu. She agonized over missing work because she had no more sick days, but she felt too weak to go in. After seeing her children off to school, she returned to bed to sleep off her symptoms. They only became worse, however, turning to cold sweats, a tight throat and pain in her jaw. Still, she stayed in bed and took over-the-counter flu medicine. Had Jane's doctor informed her of the broad range of symptoms that women experience during heart attacks, she might have known what she was, in fact, experiencing. Because she did not feel the "typical" pain in her chest and shooting pain down her arm, however, she was unaware that she was experiencing common symptoms of a heart attack.

Women's health encompasses a broad range of medical, social and economic issues, each critical to understanding the diverse needs of women. Empowering women, communities, health professionals and policymakers with the tools to recognize and combat illness can help increase the general health and well-being of all women.

Historically, the field of women's health consisted of issues surrounding reproduction and childbirth. With the increase in gender-based health research, however, women's health now is understood to encompass a multitude of diseases, symptoms and consequences-along with methods of prevention, diagnosis and treatment-that differ from men's health. Increasingly, the medical community has come to see women as a distinct patient group that has unique health concerns over a lifetime. This current focus is gaining the attention of physicians and other health professionals, as well as government officials, community activists and individual women who are working together to improve the overall quality of women's life and health.

To better understand the various dimensions of women's health, it is necessary to use a lifespan approach. This approach is informed by many factors beyond physical health, including aspects of social well-being such as child and elder caregiving, family leave issues, domestic violence and economic status. When coupled with access to health care and insurance coverage issues, factors effecting women's health become even more distinct from those that affect men.

In her book Woman's Health Care, Activist Traditions and Institutional Change, Carol Weisman maintains that a focus on women's health is not revolutionary or new, but has been a topic of importance throughout history.¹The current interest, she explains, has stimulated increased gender-based health research. Studying differences in physical systems between genders, researchers have revealed important distinctions in the effects of disease and illness on men and women. The Society for Women's Health Research, for example, reports that gender differences have been found in the composition of bone matter, metabolism of certain drugs, and level of activity of the immune system, among others.²As the scope of gender-based research has increased, it has become evident that some aspects of health and health care-such as risk factors, symptoms, detection methods, treatment, and prevention methods-can be distinct for women.

To compensate for the differences-and, in some instances, for the inequities in health care-greater focus could be placed on gender-based health research and education. Indeed, interest in gender-based research has focused attention on issues such as inequities in insurance coverage and various social factors that affect the well-being of women. Policymakers will want to be aware of the complexity of the overall health of women to help make sound policy decisions on a broad range of issues.

Traditional women's health issues such as pregnancy and birth control still are of vital importance, but they no longer define the totality of the health needs of women. Specific illnesses-heart disease and strokes, diabetes and depression, for example-as well as violence, long-term care issues, economic status, and access to health care and insurance coverage substantially affect women.

Issues Relevant to Women's Health

Reproductive Health

Although the spectrum of women's health reaches far beyond reproductive issues, reproductive health remains a vital aspect of the health of women. Most women will make reproductive health choices during their lives. These decisions include, among others, whether to have children, birth control options and choices, protection from STDs, and screening for cervical and breast cancer. Access to gynecological services provided by specialists can make a difference in the way women deal with reproductive concerns. The Kaiser Family Foundation reports that women who visit an obstetrician or gynecologist (ob/gyn) are more likely to receive recommended preventive services such as pap smears and pelvic exams. In addition, ob/gyns frequently provide more extensive counseling for family planning and STDs/HIV.³

Having access to gynecological services greatly affects the degree to which they are used. The Commonwealth Fund reports that nearly one in three women without health insurance does not receive regular preventive screening for breast and cervical cancer.⁴ Even among women with insurance, access to gynecological services can be hampered by complicated referral arrangements.

Lack of family planning services and availability of contraceptives also affect reproductive health. Both insured and uninsured women deal with barriers to family planning services and contraceptives. Although uninsured women generally lack coverage for any services, insured women also sometimes cannot afford contraceptives. Often, their health plans do not cover the full range of options.

States have taken a number of steps to increase access to gynecological and family planning services. Thirty-five states and the District of Columbia now have policies designed to allow women to self-refer for ob/gyn services without prior approval from their primary care physician.⁵Eleven states have passed legislation to expand Medicaid programs to provide low-income women greater access to family planning services, and 10 states now require comprehensive coverage of contraceptives by private health insurers.⁶ These policies represent a positive step toward greater access to gynecological services and improved reproductive health for all women.

Heart Disease and Strokes

More than 500,000 American women die each year of cardiovascular disease, including heart attacks and stroke.⁷ Yet, a 1995 Gallup poll demonstrated that four of five women and one of three primary care physicians did not know that heart disease is the leading cause of death for all women.⁸ Women also are more likely to die from heart attacks-42 percent of women who suffer heart attacks die, compared with just 21 percent of men⁹-suggesting that there are significant gender differences.

For one thing, the onset of heart disease in women often differs from that in men. While men tend to develop heart disease earlier in life, postmenopausal women are at greatest risk. The Lilly Center for Women's Health reports the risk of heart disease for postmenopausal women is double that for men of the same age and for younger women.¹⁰ The cause of the increase is unknown, however, suggesting that more research and education are needed.

Diabetes

Although men and women are diagnosed with diabetes at roughly the same rate, gender-specific complications from the disease require special attention. Women face increased risks of complications from diabetes at every milestone of life. As adolescents, they are at increased risk of obesity and eating disorders; as fertile adults, there are concerns during pregnancy; in mid-life, with postmenopausal hormone replacement, there is increased risk for depression; and as elders, they face an ever-increasing risk of heart disease.¹¹(11) Gender-specific factors warrant recognition by those who are treating women with diabetes to maximize the effectiveness of treatment and to minimize complications.

Some aspects of diabetes care transcend gender bounds. The warning signs and consequences of diabetes generally are not well known among the public. Nearly one-third of diabetics are unaware of the disease's symptoms and go without needed treatment. Substantially more people are diagnosed but do not manage their conditions properly.¹² Because untreated diabetes can lead to serious medical repercussions and even death, and because gender differences add to its complexity, public education is one way to help treat the disease appropriately.

Depression

The 1998 Commonwealth Fund Survey of Women's Health reaffirmed earlier findings that women report a higher rate of depression than men.¹³ Many factors contribute, including family care responsibilities, economic stress, physical illness, violence or abuse, and lack of social support. A high percentage of women who exhibit signs of depression also report having more difficulty obtaining care, as compared to their counterparts who are not suffering from depression. The survey also reported that one of three women who exhibits signs of depression was unable to receive needed care, such as seeing a specialist or filling a prescription, often because of cost.¹⁴ Access to appropriate and affordable health care, coupled with increased sensitivity to its causes and effects, will assist in furthering the proper care and prevention of depression.

Violence and Abuse

Two of every five American women have experienced some form of violence in their lives, and those who have are more likely to be in poor health or to develop a physical or mental illness than their counterparts who have not experienced violence or abuse.¹⁵ The Commonwealth Fund Survey of Women's Health shows that women who have experienced violence are significantly more likely to rate their health as poor (22 percent) compared to those who have not (15 percent).¹⁶

Violence against women cuts across socioeconomic lines, affecting all classes and races. Many women who report abuse to their doctors are not properly referred to support services or police.¹⁷ A lack of physician counseling and inadequate access to support services may exacerbate the problem. To help them better understand the need for adequate support services, it is important to educate physicians and communities about the long-term negative health effects of violence and abuse on women. Preventive efforts can help to ensure that violence and abuse against women stop, and the availability of support services is important to help them heal.

Long-Term Care and Medicare

On average, women have longer life expectancies than men and, as a result, they rely on the health care delivery system for many more years. Almost two-thirds of Medicare beneficiaries between the ages of 75 and 84 are women; of those age 85 and older, almost three-quarters are women.¹⁸ Because women use a disproportionate share of long-term care services, they can be more vulnerable to the associated financial burdens than men.

Currently, Medicare covers only short-term nursing home care in limited and specific situations. Thus, beneficiaries need supplemental insurance so they are not left to pay for many long-term health needs out of their own pockets (although impoverished elders may qualify for Medicaid). Medicare has high cost-sharing requirements and currently does not cover outpatient prescription drugs. Such costs often are borne disproportionately by women and it is important to examine them as a critical part of the women's health care equation.

Caregiving

The vast majority of family caregivers are women-a burden that can result in financial, emotional and physical strains that adversely affect the caregiver's health. One-fourth of women in caregiving roles report their own health as poor, and more than half have one or more chronic health condition themselves.¹⁹ Often, caregivers will go without care for themselves because of increased financial constraints and time commitments related to the care they provide, along with other family and work-related commitments. Recognition of the role that caregivers play and sensitivity to the effect that role can have on women is important. Services such as paid home health aides and increased family leave provisions for employers would assist caregivers to fulfill these essential roles.

Economic Status

Economic status also affects women's health. According to the Commonwealth Fund Survey of Women's Health, the lower a woman's income, the higher her risk for physical and mental illness.²⁰ The survey also found that low-income women are at significantly higher risk of developing chronic disease and higher levels of disabilities than are women in higher income brackets. Moreover, many social concerns disproportionately affect women's economic status. Caring for a child or an elderly or disabled relative or having a disability or illness of her own can hinder a woman's ability to obtain gainful employment. This, in turn, lowers a woman's earning potential, decreases her opportunity for work-related health benefits, and, ultimately, affects her ability to tend properly to her own health needs.

Access to Health Care and Insurance Coverage

Having access to health services and insurance coverage is important to maintaining good health, yet many women are uninsured or underinsured and lack adequate access to care. The number of uninsured women has been increasing for a decade; 18 percent of all working age women in the United States currently are uninsured.²¹ Being employed does not necessarily remedy the situation. In fact, eight of every 10 uninsured women report that they work full-time or have a spouse who works full-time.²²

Being low-income increases the risk of being uninsured. Of women living below the poverty level ($16,450 for a family of four in 1998), almost 40 percent were uninsured in 1998.²³Women with higher incomes were less likely to be uninsured. Low-income and poor women without insurance have even greater problems gaining access to care than other uninsured women. According to the Commonwealth Fund Survey, roughly half of all uninsured women said they had not received a clinical breast exam in the past year and more than half reported not having a regular primary care physician.²⁴

Meanwhile, although more men than women are uninsured overall, the gap is closing. Due to changes in welfare policy-decoupling cash assistance from health coverage under Medicaid-that occurred in 1996, many low-income women who had been on Medicaid now are uninsured even though they may be eligible for transitional Medicaid assistance. The U.S. Census Bureau's Current Population Survey shows more than 17.1 million men were without health insurance in 1998, and more than 15.7 million women also lacked coverage.²⁵

Even women who have insurance face problems with coverage gaps and poor access to needed health facilities and providers. For example, not all insured women have coverage for contraceptive services and devices because some employers or providers do not cover these services. Other employers may choose not to offer these services for religious or moral reasons. ²⁶

STATE EXAMPLES

States are approaching the issue of women's health in various ways, from maintaining a focus solely on reproductive health to collaborating on a broader range of issues. No single model exists for state implementation of women's health programs, which means that they vary depending on resources, political will and agency structure.

In Ohio, the Office of Women's Health Initiatives in the Department of Public Health is compiling data on the number of states that have women's health programs and the make-up of those programs. The latest draft of its findings indicates that eight states report having official offices of women's health within their government structure.²⁷

State officials are determining the most effective way to meet their women's health goals based on the breadth and complexity of those goals. States are developing different ways in which to integrate various medical, social and economic concerns into their approaches to women's health.

Illinois

The Illinois General Assembly first showed interest in establishing a home for women's health in 1993, when it passed a law requiring the Department of Public Health to designate a staff member to address key women's health issues. The department subsequently created a Women's Health Section within the Office of Community Health, Division of Health Promotion. In 1996, Illinois first lady Brenda Edgar launched the Illinois Women's Health Campaign-committee of community organizations, state agencies, professional associations and businesses-to address a wide range of women's health issues. The campaign conducted an expansive awareness drive to educate women and promote their health, and its success led to the transformation of the Women's Health Section into the official Office of Women's Health.

Established in 1997, the office, which has its own deputy director, has as its mission to improve the health of women through education, encouragement of healthier lifestyles, and promotion of equitable public policy on issues that affect women. The office also staffs the Interagency Cabinet on Women's Health, a panel of 11 state agency directors, and works to support a unified approach to women's health by the agencies. The office is divided into the Division of Women's Health Services, which manages direct service programs, and the Division of Technical Assistance, which fosters agency partnerships to reduce fragmentation of women's health programs. Together, the two divisions work with the Interagency Cabinet to shape effective strategies to make and implement women's health policy.²⁸

Key concerns that form the core of the office's education and awareness efforts are breast cancer, cardiovascular disease, osteoporosis, menopause, mental health and violence. The office has taken a collaborative approach to addressing the issues and is dealing with a broad range of concerns in an attempt to improve the health of Illinois women.²⁹

Taking steps toward and establishing a formal office of women's health is not the only way that states can address women's health issues. As data from the Ohio draft report show, a number of states are finding other alternatives.³⁰ Several have created sections within their departments of health, for example-usually in the family health or maternal and child health divisions-that focus on some aspects of women's health. Still other states have implemented integrated health programs-offering services to families as a whole-that show positive effects on women's health. The range of issues each program deals with and the manner in which the program is structured varies from state to state.

Washington

Washington does not have a separate office of women's health, but it does have a "cross-program workgroup" known as the Women's Health Resource Network. The network brings together individual programs within the Department of Health to collaborate and broaden the focus of their women's health efforts, while providing a forum for input and responses to current and emerging issues. Indeed, the department has many programs that touch upon women's health. Examples include programs on family planning and reproductive health, breast and cervical health, diabetes, heart health, adult immunization, domestic violence and sexual assault, and health promotion. Although each of these programs is separately funded and administered, the network brings together program representatives to create a broader collaborative understanding of women's health issues.³¹

The Women's Health Resource Network has as its goal " ... building state and local capacity to address the needs of women and their concerns throughout the lifespan."³² Its function is to coordinate issue-specific programs and encourage collaboration and idea sharing to foster more effective treatment of women's health issues.

Tennessee

Although Tennessee has not legislated a focal point within its state government to deal specifically with women's health issues, it has integrated women's health concerns into a revolutionary health care delivery program. TennCare, an innovative health care reform plan, was established statewide in 1994. The plan effectively replaces Medicaid as the means to offer low-income people health care coverage, and actually extends coverage to nearly 400,000 additional uninsured people.³³ TennCare offers health care coverage to eligible men, women and children through a system of managed care organizations (MCOs) and behavioral health organizations (BHOs) under contract with the state. The MCOs and BHOs are paid fixed monthly rates for each TennCare enrollee they serve and, in turn, they negotiate payment rates with individual care providers. Plan participants are given a choice of MCOs and BHOs within their geographical area and, once enrolled, services are delivered under the direction of a primary care physician.³⁴ The plan is funded through a combination of federal, state and local expenditures for indigent health care.³⁵

People who are Medicaid eligible, as well as children under age 19 who have no access to health insurance, certain dislocated workers and certain people with proof of uninsurability, are eligible for coverage under TennCare.³⁶ TennCare also offers presumptive eligibility to pregnant women while their full eligibility is being determined, affording them access to prenatal care during the early stages of their pregnancy. A report released by the Tennessee Department of Health shows that delivery rates among women granted presumptive eligibility greatly increased from 1993 to 1996.³⁷

The TennCare program has created a number of positive trends in women's health services in Tennessee. The Tennessee Department of Health reports that, among women receiving TennCare benefits, the number of low birth weight deliveries has decreased, prenatal care is more prevalent and begins sooner in the pregnancy, and the birth rate for adolescent females has decreased. The Department of Health also reports a decrease in the number of hospitalizations due to diabetes under the TennCare program.³⁸ Although this does not represent an advancement specific only to women's health, the decrease in hospitalizations suggests improved management of diabetes, which can have disproportionate complications for women.

The TennCare program does not focus solely on issues that affect women's health, but it does focus on improving access to care, increasing medical attention, and easing the economic burden of obtaining adequate health care for those who cannot afford it-all of which are issues directly related to women's health.

States have taken the lead in dealing with women's health issues in various ways, including considering legislative mandates for covering specific services. During the past four years, 35 states and the District of Columbia have passed laws aimed at giving women enrolled in managed care plans greater access to obstetrical and gynecological care; 10 have required comprehensive coverage of contraceptives; and 11 have adopted expanded Medicaid programs to provide low-income, uninsured women with access to family planning services.³⁹

While the federal government is slowly taking steps to address women's health, state legislatures can and have worked toward creating specific remedies for problem areas for women in their state.

FEDERAL EFFORTS TO ADDRESS WOMEN'S HEALTH

The Office of Women's Health, part of the Department of Health and Human Services (DHHS), is the federal government's focal point for women's health issues. The office works to redress inequities in research and health care services by overseeing collaboration of agencies within DHHS, other relevant government entities, and consumer and health care professional groups. The office focuses on such issues as breast health, adolescent health, reproductive health, access to care, minority health and violence against women.⁴⁰

In addition, the office funds 17 National Centers of Excellence in Women's Health and conducts various other outreach programs. Developed to provide state-of-the-art comprehensive health services for the special needs of women, the centers integrate health care services, research programs, public education and health care professional training.⁴¹

Education and outreach activities are conducted through the Office of Women's Health in an effort to give consumers and the private sector a voice in the formation of women's health policy. Activities and programs include the National Women's Health Information Center (access to information by Internet or toll-free phone lines), the National College Roundtable on Women's Health (on-campus discussions with college-age women to provide information on making smart health decisions), and the National Directory of Women's Health Residency and Fellowship Opportunities in Medicine (to increase public and professional awareness of post-graduate training programs in women's health).⁴²

Congress also has brought women's health issues to the forefront. During the 1999 session, bills on the following issues (among others) were introduced: improved access to obstetric and gynecological care; establishment of an osteoporosis screening and prevention program; repeal of the interim payment system for home health services under Medicare; a House resolution on heart disease in women; and Medicaid coverage for uninsured women who are diagnosed with breast or cervical cancer. With the current focus on women's health, legislative and administrative efforts to address such issues may increase over time.

Conclusions

It is important for state policymakers to become involved in setting the agenda for women's health care policy. State legislators are in a position to examine the specific needs of their states and to develop effective policies to address those issues.

A key goal of work focused on women's health is to promote and improve the health status of women across their lifespan. Recognizing that a combination of factors-social, economic, cultural, behavioral and biological-affect women's health allows legislators to consider policies that address many of those concerns. Awareness of the issues involved in women's health will be helpful for legislators and will help create a better understanding of the effect that policies can have for women's health.

Acknowledments

The author would like to thank Leann Stelzer and Kate Davis at the National Conference of State Legislatures for their editing and formatting assistance. Thanks also to the following people who offered valuable information and review assistance: J. Zoe Beckerman of the Henry J. Kaiser Family Foundation; Alina Salganicoff of the Henry J. Kaiser Family Foundation; Carol S. Weisman of the University of Michigan School of Public Health, Department of Health Management and Policy; and John McDonough, associate professor at the Institute for Health Policy of the Heller School at Brandeis University.

Notes

1. Carol S. Weisman, Women's Health Care, Activist Traditions and Institutional Change (Baltimore: Johns Hopkins University Press, 1998).

2. Society for Women's Health Research, Gender Based Biology, 1999; obtained from www.womens-health.org/gbb.html.

3. The Henry J. Kaiser Family Foundation, State Policies on Access to Gynecological Care and Contraception, Issue Brief (Washington, D.C.: The Henry J. Kaiser Family Foundation, November 1999).

4. Karen Scott Collins et al., Health Concerns Across a Woman's Lifespan: 1998 Survey of Women's Health, (New York, N.Y.: The Commonwealth Fund, 1999), 2.

5. The Henry J. Kaiser Family Foundation, State Policies on Access to Gynecological Care and Contraception, Issue Brief (Washington, D.C.: The Henry J. Kaiser Family Foundation, November 1999).

6. Ibid.

7. American Heart Association, 2000 Heart Attack and Stroke Statistical Update, obtained from www.americanheart.org.

8. American Heart Association, Heart Attack, Stroke and other Cardiovascular Diseases, obtained from www.americanheart.org.

9. American Heart Association, Women, Heart Disease and Stroke Statistics, 1999, obtained from www.americanheart.org/Heart_and_Stroke_A_Z_Guide/womens.html.

10. Lilly Center for Women's Health, "Post Menopausal Health," Women's Health Matters 3, no. 1 (Spring 1999), 2.

11. Karen E. Friday, M.D., "Estrogen Replacement Therapy for Post Menopausal Women with Diabetes," Diabetes Spectrum, 10, no. 2 (1997), 203-206.

12. Nicole Johnson, "Guest Column," Women's Health Matters 3, no. 2 (Summer 1999), 1.

13. Karen Scott Collins et al., Health Concerns Across a Woman's Lifespan: 1998 Survey of Women's Health (New York, N.Y.: The Commonwealth Fund, 1999), 10.

14. Ibid., 11.

15. Ibid., 7.

16. Ibid., 8.

17. Ibid., 9.

18. The Henry J. Kaiser Family Foundation, Medicare and Women (The Henry J. Kaiser Family Foundation) obtained from www.kff.org.

19. The Commonwealth Fund, Informal Caregiving (New York, N.Y.: The Commonwealth Fund, May 1999).

20. Karen Scott Collins et al., Health Concerns Across a Woman's Lifespan: 1998 Survey of Women's Health (New York, N.Y.: The Commonwealth Fund, 1999), 13.

21. Ibid., 15.

22. Ibid., 16.

23. Kaiser Commission on Medicaid and the Uninsured, Analysis of March 1999 Current Population Survey (The Henry J. Kaiser Family Foundation, Washington, D.C., 2000 unpublished report)

24. The Commonwealth Fund, Health Insurance Coverage and Access to Care for Working Age Women, (New York. N.Y.: The Commonwealth Fund , May 1999), 2.

25. Kaiser Family Foundation (unpublished estimates by the Urban Institute of the current population survey, 1999).

26. The Henry J. Kaiser Family Foundation, State Policies on Access to Gynecological Care and Contraception, Issue Brief (Washington, D.C.: The Henry J. Kaiser Family Foundation, November 1999).

27. States with an official office of women's health (according to Ohio draft report): California, Illinois, Indiana, Maryland, Missouri, North Carolina, Ohio and Wisconsin.

28. Sharon Green, deputy director, Illinois Office of Women's Health, Establishing a State Office of Women's Health: Lessons Learned from the Illinois Experience, (Chicago: Illinois Department of Public Health, 1999).

29. Ibid.

30. States that have no formal office of women's health, but that have a women's health program (according to Ohio draft report): Arkansas, Colorado, Florida, Hawaii, Iowa, Massachusetts, Minnesota, Nebraska, Nevada, New York, Pennsylvania, Rhode Island, Texas, Utah, Vermont, Washington and West Virginia.

31. Washington State Department of Health, Women's Health Program Fact Sheet (Olympia, Wash.: Washington State Department of Health, 1999).

32. Ibid.

33. State of Tennessee, Bureau of TennCare, obtained from www.state.tn.us/health/tenncare/about.htm.

34. Ibid.

35. Ibid.

36. State of Tennessee, Bureau of TennCare, obtained from www.state.tn.us/health/tenncare/eligibil.htm.

37. State of Tennessee, Department of Health News Release, TennCare Report on Women's Health Shows Upward Trends, January 17, 1998.

38. State of Tennessee, Department of Health News Release, TennCare Helps Diabetic Stay Healthy, February 19, 1998.

39. The Henry J. Kaiser Family Foundation, State Policies on Access to Gynecological Care and Contraception, Issue Brief-An Update on Women's Health Policy (Washington, D.C.: The Henry J. Kaiser Family Foundation, November 1999), 2.

40. Federal Office of Women's Health, obtained from www.4woman.org/owh/about.

41. Federal Office of Women's Health, National Centers of Excellence, obtained from www.4woman.org/owh/coe.

42. Federal Office of Women's Health, Communication and Outreach, obtained from www.4woman.org/owh/prog/commun.htm.