HEALTH OF WOMEN AND CHILDREN REPORT

HEALTH OF WOMEN AND CHILDREN REPORT MARCH 2018 The full report is available at www.americashealthrankings.org

OVERVIEW Promoting the health of women, infants and children is fundamental to keeping our communities and nation healthy both today and for future generations. Community leaders, public health officials and policymakers can help build better communities by understanding the health of women during their reproductive years, infants and children. This year, United Health Foundation is proud to continue to identify areas of success as well as challenges for the health of women, infants and children. America s Health Rankings Health of Women and Children Report utilizes 62 health indicators, including those that examine the community and environment, clinical care, behaviors, policies and health outcomes, to better understand the changing health of women and children across the country and state-by-state. America s Health Rankings data serve as an important benchmark for communities across the country as they work to improve the health and well-being of women, infants and children. By looking separately at their health, states can focus efforts on areas where improvement is most needed. The updated data continue to serve the public health community by providing one of the most comprehensive assessments of the health of women, infants and children at the national and state levels. For 29 years, America s Health Rankings has provided a wide variety of health and health-related information to help policymakers, advocates and individuals understand the health of key populations in a holistic, inclusive manner. This year s update to the Health of Women and Children Report builds on that commitment, providing insights on women of reproductive age and children, who together compose more than 40 percent of the total U.S. population. Research shows that health develops over a lifetime and markers of prenatal and childhood health are significant predictors of health and economic status in adulthood. United Health Foundation recognizes that the health of America s women, infants and children today will impact the future well-being of the United States for generations to come. 2

women and children ha since AHR's 2016 Health of Women and Children Report. SUMMARY OF KEY FINDINGS MATERNAL MORTALITY BY RACE/ETHNICITY PROGRESS Encouraging Declines in Tobacco Use the nation has made encouraging progress BY RACE / ETHNICITY in regard to the prevalence of smoking among women and children. 14.4 BLACK 12.0 Progress Made Across Key Markers of Care this year s update finds that progress has been INCREASED made in key measures of clinical care, including an increase in the AMERICAN INDIAN percentage of women with a dedicated health INCREASED care provider; a decline in the percentage 19.9 of uninsured women; and a decline in teen births. +20% CHALLENGES Deaths per 100,000 live births Concerning Increases in Key Mortality Rates key measures of mortality for both women and children Key Key mortality measures for for women and and children have increased have increased since 2016, including: an increase in the rate of drug deaths among ASIAN / PACIFIC females aged 15-44; ISLANDER since AHR's 2016 Health of of Women and and Children Report. 11.6 and an increase in the nation s maternal mortality rate per 100,000 live births. Notable Differences in Mortality Rates Across States mortality rates for women and children vary widely across states, highlighting alarming health disparities across state lines. MATERNAL MORTALITY BY BY RACE/ETHNICITY Striking inequities in mortality rates across women, infants and children. Wide variation across states for the rate of well-visits DRUG for women, DEATH DRUG infants and BY adolescents. AGE THE THE OF DRUG OF DRUG CONCERNING INCREASES IN KEY MORTALITY S BLACK BLACK 47.2 47.2 INCREASES 8.4 INCREASES WITH WITH AGE AGE INCREASED Nationally, key measures of mortality for AMERICAN both INDIAN 14.4 INDIAN women 14.4 and children have increased since the 2016 & ALASKA NATIVE 38.8 Health of Women and 38.8 INCREASED Children Report. (This is the most recent time that the report was +6% 35 44 12.0 35 44 12.0 21.0 21.0 created.) 2016 Edition 2016 Edition INCREASED 19.9 19.9 20.7 20.7 2016 Edition 2016 Edition +4% OF OF MATERNAL MORTALITY BY BY RACE RACE / ETHNICITY / WHITE WHITE 18.1 18.1 +20% FROM FROM 12.0 TO 12.0 14.4 TO 14.4 The rate of drug deaths increased 20 percent per 100,000 females aged 15-44. FROM FROM 19.9 19.9 TO TO 20.7 20.7 2016 Edition Deaths Deaths per 100,000 per 100,000 live births live births Deaths The teen suicide rate has increased 6 percent per 100,000 12.2 12.2 per Deaths 100,000 adolescents per aged 15-19. 100,000 24 20.7 The nation s maternal mortality rate increased ASIAN ASIAN / PACIFIC 4 / PACIFIC Deaths per percent per 100,000 live births, which Deaths 100,000 measures per 100,000 females from females 2018 deaths from Edition 2018 Edition ISLANDER ISLANDER +4% FROM 19.9 TO 20.7 11.6 11.6 from any cause related to or aggravated by pregnancy and childbirth. Deaths Deaths per 100,000 per 100,000 live births live births from from 2018 2018 Edition Edition 25 3425 34 8.9 15 246.0 6.0 FROM 12.0 TO 14.4 18.1 Deaths per 100,000 females aged 15-44 Key mortality measures for Deaths per 100,000 live births from 2018 Edition women and children have increased. +20% females females aged 15-44 aged 15-44 OF MATERNAL MORTALITY WHITE 12.2 38.8 FROM 8.4 TO 8.9 16.6 Deaths per 100,000 16.6 adolescents aged 15-19 47.2 DRUG DEATH TEEN SUICIDE TEEN MATERNAL TEEN SUICIDE SUICIDE MORTALITY BY RACE BY RACE / ETHNICITY / ETHNICITY 14.4 14.4 TEEN SUICIDE TEEN BY SUICIDE RACE/ETHNICITY DRUG DEATH BY BY AGE 12.0 12.0 2016 Edition 2016 Edition INCREASED +20% FROM FROM 12.0 12.0 TO TO 14.4 14.4 Deaths Deaths per 100,000 per 100,000 females females aged aged 15-44 15-44 THE THE OF OF DRUG DRUG INCREASES WITH WITH AGE AGE 8.9 8.9 8.4 8.4 INCREASED 35 35 44 44 21.0 21.0 25 25 34 34 16.6 16.6 +6% 2016 Edition 2016 Edition FROM FROM 8.4 TO 8.4 8.9 TO 8.9 15 15 24 24 Deaths 6.0 6.0 per Deaths 100,000 per 100,000 adolescents adolescents aged 15-19 aged 15-19 +6% AMERICAN AMERICAN INDIAN INDIAN & ALASKA NATIVE 16.6 16.6 WHITE WHITE 10.4 19.9 20.7 10.4 INCREASED +4% 2016 ASIAN Edition ASIAN 7.2 7.2 FROM 19.9 TO 20.7 6.4 Deaths 6.4 per 100,000 live births RA BY Deaths Deaths per 100,000 per 100,000 females females from from 2018 2018 Edition Edition BLACK BLACK 5.5 5.5 A Deaths per Deaths 100,000 per 100,000 adolescents adolescents aged 15-19 aged from 15-19 2018 from Edition 2018 Edition TEEN SUICIDE BY BY RACE/ETHNICITY KEY AREAS OF PRO CHILD MORTALITY MATERNAL BY MORTALITY RACE/ETHNICITY TEEN TEEN SUICIDE BY BY RACE RACE / ETHNICITY / 3 8.9 8.9 AMERICAN INDIAN INDIAN & ALASKA NATIVE 16.6 16.6 CHILD ENCOURAGING MORTALITY OF MATERNAL MORTALITY DECLINES BY RACE BY RACE / / ETHNICITY IN ETHNICITY TOBACCO USE

The report also finds striking inequities in mortality rates across women, infants and children, highlighting the health challenges that different groups face. Drug ISLANDER death rates are higher among women aged 35-44 compared with those aged 15-24 and 25-34. The maternal mortality rate among black women is 2.5 times higher than the rate among white women and 4 times higher than the rate among Asian/Pacific Islanders and Hispanic women; the rate among white women is about 1.5 times higher than the rate among TEEN Asian/Pacific SUICIDE Islander and Hispanic women. BY RACE / ETHNICITY Teen suicide rates are highest among American Indian & Alaska Native teens, followed by white, Hispanic and black teens. AMERICAN INDIAN 8.9 16.6 Black children face the highest child mortality rate among racial/ethnic groups more than 2 times H BY AGE THE higher than OF DRUG the rate for Asian children and 1.5 times higher than the rate for white children. 8.4 WHITE INCREASES WITH AGEINCREASED 10.4 2016 Edition +6% THE OF DRUG OF MATERNAL MORTALITY INCREASES 35 44 WITH AGE BY RACE ASIAN 21.0 / ETHNICITY 7.2 FROM 8.4 TO 8.9 35 25 44 34 25 15 34 24 WHITE y measures for 19.9 20.7 +6% FROM 8.4 TO 8.9 18.1 Deaths per 100,000 12.2 adolescents aged 15-19 ASIAN / PACIFIC ren have increased. INCREASED +4% 2016 Edition Deaths per 100,000 15 24 females from 2018 Edition 6.0 BLACK AMERICAN INDIAN BLACK Deaths per 100,000 females from 2018 Edition TEEN 11.6 SUICIDE BY RACE/ETHNICITY Deaths per 100,000 live births from 2018 Edition Deaths per 100,000 16.6 21.0 adolescents aged 15-19 6.0 16.6 6.4 5.5 47.2 38.8 Deaths per 100,000 adolescents aged 15-19 from 2018 Edition WHITE 18.1 FROM 19.9 TO 20.7 Deaths per 100,000 females from 2018 Edition Deaths per 100,000 live births 12.2 SUICIDE AMERICAN INDIAN WHITE ASIAN / PACIFIC ISLANDER 11.6 CHILD MORTALITY BY RACE/ETHNICITY E BY RACE/ETHNICITY TEEN SUICIDE BY RACE / ETHNICITY TEEN SUICIDE AMERICAN INDIAN BY RACE / ETHNICITY ENCOURAGING 21.8 DECLINES WHITE ASIAN IN TOBACCO USE +2% 22.3 7.2 10.4 2016 Edition ASIAN BLACK BLACK KEY AREAS OF PROGRESS 16.6 INCREASED 16.6 10.4 FROM 21.8 TO 22.3 Deaths per 100,000 6.4 7.2 children aged 1-18 Smoking among women (aged 18-44) DECREASED 10% (from 17.4% to 15.6%). 5.5 6.4 Tobacco use during pregnancy DECREASED 7% Deaths per 100,000 adolescents aged 15-19 from 2018 Edition (from 8.4% to 7.8%). 5.5 Tobacco use among youth (aged 12-17) DECREASED 23% Deaths per 100,000 adolescents aged 15-19 from 2018 Edition (from 7.4% to 5.7%). BLACK AMERICAN INDIAN Deaths per 100,000 live births from 2018 Edition CHILD MORTALITY BY RACE / ETHNICITY 31.9 24.6 PROGRESS ACROSS KEY MARKERS WHITE OF CLINICAL CARE ASIAN 20.8 27% DECLINE in the percentage 18.3 of uninsured (from 16.8% to 12.2%). 14% INCREASE in the percentage of 13.5 infants breastfed exclusively for six months. Deaths per 100,000 8% DECLINE children aged in the 1-18 births from 2018 among Edition teens (aged 15-19). 3% INCREASE of women (aged 18-44) report having a dedicated health care provider (from 71.6% to 73.7%). 4

The rates of key mortality measures for women and children are as much as ten times higher in one state versus another. The rates of key mortality measures for women and children are asrates much ten times higher in one versus another.are The ofas key mortality measures forstate women and children as much as ten times higher in one state versus another.are The rates of key mortality measures for women and children OF DRUG AMONG FEMALES Deaths per 100,000 females aged 15-44 as much as ten times higher in one state versus another. NOTABLE S IN MORTALITY S ACROSS STATES Mortality rates for women and children vary widely across states, highlighting startling health disparities across state lines. Some states experience mortality rates as much as ten times higher than other states. For example, West Virginia has the highest drug death rate among women aged 15-44 (at 41.6 deaths per 100,000), while Hawaii has the lowest drug death (5.5 deaths per 100,000) rate among this population. Even greater differences are found when looking at maternal mortality. Georgia experiences the highest rate (at 46.2 deaths per 100,000), while California experiences the lowest rate (at 4.5 deaths per 100,000). Teen suicide is another measure where large differences are reported across states. Rhode Island has the lowest teen suicide rate in the country among adolescents aged 15-19 (at 4.7 deaths per 100,000) which is one-eighth the teen suicide rate in Alaska (at 35.1 deaths per 100,000), the state with the highest rate in the country. States face stark differences in child mortality, as South Dakota, the state with the highest child mortality rate among children aged 1-18 (at 36.4 deaths per 100,000), has a rate three times higher than Connecticut, the state with the lowest rate (at 12.8 deaths per 100,000). OF DRUG AMONG FEMALES WEST VIRGINIA Deaths per 100,000 females aged 15-44 HAWAII OF DRUG AMONG FEMALES Deaths per 100,000 females aged 15-44 OF DRUG AMONG FEMALES WEST VIRGINIA HAWAII Deaths per 100,000 females aged 15-44 WEST VIRGINIA HAWAII WEST VIRGINIA HAWAII 41.6 41.6 41.6 41.6 5.5 5.5 5.5 5.5 8X 8X 8X 8X MATERNAL MORTALITY Deaths per 100,000 live births GEORGIA GEORGIA GEORGIA GEORGIA 46.2 46.2 46.2 46.2 MATERNAL MORTALITY Deaths per 100,000 live births MATERNAL MORTALITY Deaths per 100,000 live births MATERNAL MORTALITY Deaths per 100,000 live births CALIFORNIA CALIFORNIA CALIFORNIA CALIFORNIA 4.5 4.5 4.5 4.5 10X 10X 10X 10X TEEN SUICIDE Deaths per 100,000 adolescents aged 15-19 ALASKA ALASKA ALASKA ALASKA 35.1 35.1 35.1 35.1 TEEN SUICIDE Deaths per 100,000 adolescents aged 15-19 TEEN SUICIDE Deaths per 100,000 adolescents aged 15-19 Deaths per 100,000 adolescents aged 15-19 TEEN SUICIDE 4.7 4.7 4.7 4.7 7.5X 7.5X 7.5X 7.5X CHILD MORTALITY Deaths per 100,000 children aged 1-18 SOUTH DAKOTA SOUTH DAKOTA SOUTH DAKOTA SOUTH DAKOTA 36.4 36.4 36.4 36.4 CHILD MORTALITY Deaths per 100,000 children aged 1-18 CHILD MORTALITY Deaths per 100,000 children aged 1-18 CHILD MORTALITY Deaths per 100,000 children aged 1-18 3X 3X 3X 3X CONNECTICUT CONNECTICUT CONNECTICUT CONNECTICUT 12.8 12.8 12.8 12.8 For more information please visit us at www.americashealthrankings.org 5 For more information please visit us at www.americashealthrankings.org For more information please visit us at www.americashealthrankings.org

ths 12.2 ENCOURAGING DECLINES IN TOBACCO USE ENCOURAGING DECLINES Since the 2016 Health ASIAN of Women / PACIFIC and Children Report, the nation has made encouraging progress in regard to the prevalence ISLANDER IN TOBACCO of smoking among women 11.6 USE and children. Three notable areas where smoking rates have declined during this time include: AS OF PROGRESS Deaths per 100,000 live births from 2018 Edition Smoking among women (aged 18-44) DECREASED 10% (from 17.4% to 15.6%). Tobacco use during pregnancy DECREASED 7% (from 8.4% to 7.8%). Tobacco use among youth (aged 12-17) DECREASED 23% (from 7.4% to 5.7%). % % However, wide disparities in tobacco use and exposure persist across states. West Virginia, for example, has a prevalence of smoking among women 4 times higher than California and Utah, the states with the lowest rates for this measure. PROGRESS MADE ACROSS KEY MARKERS OF CARE In addition to improved national smoking rates, this year s update finds that progress has been made in key measures of clinical care. A higher percentage of women aged 18-44 report having a dedicated health care provider (from 71.6 percent to 73.7 percent) and the country has seen a sizable decline in the percentage of uninsured among this population (from 16.8 percent to 12.2 percent). Also encouraging is the decline in births among teens, with 8 percent fewer births per 1,000 females aged 15-19 compared to the 2016 findings, as well as an increase in the percentage of infants breastfed exclusively for six months rising 14 percent. PROGRESS ACROSS KEY MARKERS OF CLINICAL CARE 27% DECLINE in the percentage of uninsured (from 16.8% to 12.2%). 14% INCREASE in the percentage of infants breastfed exclusively for six months. 8% DECLINE in the births among teens (aged 15-19). 3% INCREASE of women (aged 18-44) report having a dedicated health care provider (from 71.6% to 73.7%). 6

1 1 2 2 MASSACHUSETTS NEW HAMPSHIRE 3 3 4 4 5 5 VERMONT MINNESOTA VARIED S OF PREVENTIVE CARE USE ACROSS THE COUNTRY This year s report finds wide variation across states for the rate of well-visits for women, infants MASSACHUSETTS NEW HAMPSHIRE VERMONT MINNESOTA and adolescents. Nationally, 90.7 percent of babies aged 0-2 years received well-baby checks, but among states, it varies from a low of 83.0 percent in Texas to an encouraging high of 98.8 percent in Ohio. Looking at adolescents, 78.9 percent received a well-visit in the last year, while only two-thirds of Alaska teens aged 12-17 received a well-visit in the past year, compared with nearly 90 percent of teens in Delaware. THE STATES WITH THE BIGGEST CHALLENGES THE STATES WITH THE BIGGEST CHALLENGES 50 49 48 50 49 48 47 46 47 46 Finally, about two-thirds of women received a well-visit nationally, but notable differences exist regionally. Rates for well-woman visits are generally higher among states east of the Mississippi and lower in Texas, Alaska and mountain states. Notably, the prevalence of well-visits varies among women, infants and adolescents within states, calling special attention to the need for states to take a holistic approach to improving rates of preventive care use among women, infants and children. Only Massachusetts has high rates for well-visits across women, infants and adolescents. Immunization ratesoklahoma for children and adolescents MISSISSIPPI ARKANSAS LOUISIANA ALABAMA similarly vary by state, with the immunization rate for children aged 19 to 35 months being nearly 1.5MISSISSIPPI times higher in Massachusetts than the statelouisiana with the lowest immunization coverage, Oregon. ARKANSAS OKLAHOMA ALABAMA HEALTHIEST STATES FOR WOMEN, INFANTS AND CHILDREN VT NH WA OR WA MT ID OR NV CA CA MT WY ID NV UT AZ AZ AK WY CO UT ND SD ND SD NE NE KS MN WI MNIA IA MO CO NM KSOK MO AR NM OK TX AR LA AK TX LA WI IL IL VT NH NY ME MI PA NY MI OH IN KY IN OH TN KY AL MS TN MS AL ME PA VA NC VA SC NC GA SC GA FL MA RI MA CT RI NJ CT DE NJ MD DE DC MD WV DC WV FL HI HI RANK: RANK: 1 to 10 1 to 10 11 to 20 11 to 20 21 to 30 31 to 40 21 to 30 31 to 40 41 to 50 41 to 50 Not Ranked Not Ranked 7

2018 Women and Children Rankings This year s update ranked each state across 62 measures to compare how states are performing across the health of women, infants and children. Massachusetts (No. 1) and New Hampshire (No. 2) take the top two spots, followed by Rhode Island (No. 3), Vermont (No. 4) and Minnesota (No. 5). THE HEALTHIEST STATES 1 2 3 4 5 MASSACHUSETTS NEW HAMPSHIRE VERMONT MINNESOTA Mississippi ranks as the state with the most challenges for women, infants and children. The state is followed by Arkansas (No. 49), Louisiana (No. 48), Oklahoma (No. 47) and Alabama (No. 46) as states with the greatest opportunities improvement. THE STATESfor WITH THE BIGGEST CHALLENGES 50 49 48 MISSISSIPPI ARKANSAS 47 46 LOUISIANA OKLAHOMA ALABAMA The rankings are generally consistent with those of the Annual Report, which ranks each state s overall health. The Annual Report found that the Northeast is the healthiest region in the country and that Mississippi also had the greatest opportunities for improvement overall. VT NH WA OR MT ND MN ID ID SD WI POPULATIONS FARE DIFFERENTLY WITHIN STATES WY MI NY ME MA RI PAranks the health of each IA Health Rankings In addition to providingnv overall state rankings, NEAmerica s CT OH IL IN UT population individually. CA NJ CO VA KS MO KY DE For women, Massachusetts, Vermont and Minnesota rank as the top three states; NC Texas, Louisiana and TN MD OK AZ Arkansas have the greatest opportunity NMfor improvement. AR SC DC AL GA For infant health, New Hampshire, California and Oregon are MS strongest; Mississippi, West Virginia and LA WV Alabama face AK the greatest challenges. TX Children are healthiest in Massachusetts, Connecticut and New Hampshire;FLMississippi, Alaska and Oklahoma have the lowest scores for this population group. HI 8 RANK: 1 to 10 11 to 20 21 to 30 31 to 40 41 to 50 Not Ranked

CONCLUSION The public health issues illuminated by this year s data update to the Health of Women and Children Report reveal opportunities for improvement across the three studied populations as well as successes, including a reduction in smoking and tobacco use across the country. Findings from this update, coupled with the broader suite of America s Health Rankings data, provide important insights to help communities craft data-driven solutions to some of the nation s most pressing health concerns. United Health Foundation is proud to lead this effort through America s Health Rankings as a roadmap for healthier communities. 9

For more information, contact: L.D. Platt United Health Foundation (202) 654-8830 ld_platt@uhg.com www.americashealthrankings.org