DOI: 10.1097/GCO.0b013e328340fffa
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PMID: 21048461
Issn Print: 1040-872X
Publication Date: 2010/12/01
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Excerpt
Although ACA has been enacted, the work of healthcare reform is not done. In fact, it has only begun. Expanding healthcare coverage is only a precondition for healthcare reform; it is necessary, but not sufficient for improving women's health in America. In this section, I will propose a few key ‘next steps’ in healthcare reform for improving women's health.
There is now a paradigm shift in women's health. Increasingly, health is viewed as the product of a dynamic, complex interplay of biological, behavioral, psychological, and social and environmental factors over a woman's life course [3]. This so-called life-course perspective has two major components: early programming and cumulative pathways. The early programming model posits that events early in life, including intrauterine exposures, can influence one's health and function for life [4,5]. This model grew out of the work of Barker [4] (so-called ‘Barker hypothesis’) and has grown into a large body of scientific research collectively known as developmental origins of health and disease [5]. Key concepts include timing (e.g., sensitive and critical periods) and trajectory. Examples include how prenatal undernutrition may result in fewer β-cells in the pancreas or nephrons in the kidneys [4], which may not always predict disease outcomes in later life, but may define capacity and limit potential over the life course.
The cumulative pathways model is a model of risk accumulation. It posits that risks and insults accumulate over the life course through episodes of illness or injury, adverse social circumstances, toxic environmental exposures, and unhealthful behaviors [6]. These exposures and insults can create wear and tear (what McEwen [7] termed ‘allostatic load’) on the body's homeostatic mechanisms, leading to declines in health and function over time. This cumulative pathways model grew out of life-course chronic disease epidemiology [6]. Key concepts include weathering [8] (or allostatic load [7], which refers to the physiological toll of weathering) and pathway, which refers to the observation that these risks and insults do not occur randomly, but rather cluster in socially patterned ways to produce socioeconomic gradient or racial–ethnic disparities in health [9]. Examples include how chronic stress can create wear and tear to the body's allostatic mechanisms, and that hypothalamic–pituitary–adrenal axis, immuneinflammatory, and metabolic dysregulations can over time lead to the development of cardiovascular diseases and metabolic syndrome [7].
Healthcare can play a vital role in shaping how women's health develops over the life course, but only if it is designed to do so. Our so-called system of women's healthcare is presently not set up to optimize women's health development across the lifespan. For example, prenatal care, in its present form, is not designed to deliver nutritional counseling, improve dietary quality, and address food insecurity in an efficient and effective way. This represents an important missed opportunity in prenatal care to optimize women's health and developmental programming that may have long-term impact on mother and baby. Healthcare reform offers an extraordinary opportunity to reinvent women's healthcare – to redefine essential services for women's healthcare, to redesign organization and delivery of women's healthcare, and to invest in primary prevention and health promotion – in order to improve women's health over the life course.
