Poverty and politics: their impact on women's reproductive

health outcomes over time 

By Richard M. KimballMSN/MPH, PHCNS-BC, PhD, RN

APHA – New Orleans ; Tuesday 18 Nov. 2014 Session 4169.0 Abortion and Reproductive Rights: History and

Current Politics

Presenter Disclosures

(1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

Richard M. Kimball

No relationships to disclose

Policy Backdrop

US health care• $7771 per capita• 39th in world• Life Expectancy = 78• IMR = 6.6 • Teen Births = 41.5• Abortions = 19.6

Social Determinants of Health• Income Inequality• Poverty Rates• Polarized elections • Religious orthodoxy

Navarro et al. 2006

Link Politics & Policy with Health Outcomes

Red vs. Blue States2004 Election 2008 Election

Blue Red Blue RedStates 19 31 28 22

Women's Reproductive Health OutcomesIMR 6.05 7.35 6.21 7.23Teen Births 26.6 46.2 35.0 49.5Abortions 20.6 12.0 19.8 10.3Social Determinants of HealthPoverty 10.5% 13.0% 11.4% 13.7%Religiosity* 47.8% 60.4% 50.2% 62.5%

Presidential Election 2004

Presidential Election 2008

Purple States

How do states compare?

IMR Teen Births Religion Poverty Abortion Election

State 2004 2008 2004 2008 2004/08 2004 2008 2004 2008 2004 2008

New Hampshire 5.63 3.87 18.2 19.8 36% 7.6% 7.5% 11.7 12.3 Blue Blue

Massachusetts 4.80 5.04 22.3 20.1 40% 9.2% 10.1% 19.9 18.3 Blue Blue

California 5.16 5.11 39.5 38.4 48% 13.3% 13.4% 27.1 27.6 Blue Blue

Virginia 7.35 6.88 35.2 33.5 59% 9.5% 10.3% 16.5 17.6 Red Blue

Texas 6.28 6.17 62.6 63.4 67% 16.6% 16.0% 17.3 16.5 Red Red

Louisiana 10.31 9.04 56.2 54.1 73% 19.4% 17.4% 11.7 16.1 Red Red

Mississippi 9.90 9.95 61.9 65.7 82% 21.6% 21.4% 4.9 4.6 Red Red

Correlations- 2004/2008

2008Health

Outcomes Poverty Religiosity 2008 ElectionIMR 0.49 0.70 0.39

Teen Births 0.72 0.70 0.59Abortion -0.16* -0.25* -0.57

*NOT SSCohen, effect sizes = 0.1 small, 0.3 medium, 0.5 large

2004 Health

Outcomes Poverty Religiosity 2004 ElectionIMR 0.50 0.71 0.44

Teen Births 0.72 0.71 0.68Abortion -0.18* -0.29 -0.51

Regression Results- 2004IMR β Coef. SE t p-value 95% Conf. Interval R2=0.52

Religion 0.09 0.02 4.37 0.00 0.05 0.13Poverty 0.05 0.07 0.73 0.47 -0.08 0.18Election '04 0.10 0.37 0.27 0.79 -0.65 0.86Intercept 1.44 0.87 1.67 0.10 -0.30 3.19

Teen Births β Coef. SE t p-value 95% Conf. Interval R2=0.72Religion 0.26 0.12 2.09 0.04 0.01 0.50Poverty 1.70 0.41 4.15 0.00 0.88 2.52Election '04 9.09 2.34 3.88 0.00 4.38 13.81Intercept -0.45 5.42 -0.08 0.93 -11.35 10.45

Abortion β Coef. SE t p-value 95% Conf. Interval R2=0.27Religion -0.02 0.14 -0.18 0.86 -0.30 0.25Poverty 0.16 0.45 0.35 0.73 -0.75 1.06Election '04 -8.66 2.58 -3.36 0.00 -13.85 -3.47Intercept 20.07 5.96 3.37 0.00 8.07 32.08

Regression Results- 2008IMR β Coef. SE t p-value 95% Conf. Interval R2=0.50

Religion 0.08 0.02 4.49 0.00 0.04 0.11Poverty 0.06 0.06 1.05 0.30 -0.06 0.18Election '08 -0.08 0.33 -0.25 0.80 -0.76 0.59Intercept 1.60 0.83 1.92 0.06 -0.08 3.27

Teen Births β Coef. SE t p-value 95% Conf. Interval R2=0.67Religion 0.35 0.13 2.65 0.01 0.09 0.62Poverty 1.89 0.44 4.29 0.00 1.00 2.77Election '08 5.82 2.55 2.28 0.03 0.69 10.96Intercept -4.23 6.34 -0.67 0.51 -16.99 8.54

Abortion β Coef. SE t p-value 95% Conf. Interval R2=0.33Religion 0.06 0.13 0.48 0.64 -0.20 0.32Poverty 0.14 0.43 0.33 0.75 -0.72 1.00Election '08 -10.64 2.48 -4.30 0.00 -15.62 -5.65Intercept 15.14 6.16 2.46 0.02 2.74 27.54

Interpreting the Results: IMR• As Religion scores increase by 1%, IMR is

predicted to increase by 0.08-0.09 per 1,000 (or 1.2-1.3% at the mean in 2004/2008). • That is a predicted 3.7-4.2 per 1,000 increase in IMR

from the least religious to the most religious states.• 50-52% of the variance in IMR among the states

explained by the models.

State Religion IMR 2008

New Hampshire 36% Least 3.9 Lowest

Mississippi 82% Most 10.0 Highest

State Religion 2008

Vermont 36% Least 4.4 Lowest

Louisiana 73% High 10.3 Highest

Teen Births• As Religion scores increase by 1%, the teen birth

rate is predicted to increase by 0.26/0.35 per 1,000 • That is a predicted 12/16 per 1,000 increase in teen

births from the least religious to the most religious states.

• As poverty rates increase by 1%, the teen birth rate is predicted to increase by 1.7/1.9 per 1,000 • That is a predicted 24/26 per 1,000 increase in teen

births from the lowest to highest poverty states.

• Voting “Red” in ‘04/‘08 Presidential election, predicts a 9.1/5.8 per 1,000 increase in teen births• 67-72% of the variance in teen births explained by models.

State Election ‘08 Poverty 2008 Teen Birth Rate 2008New Hampshire Blue 7.5% Lowest 19.8/1,000 LowestMississippi Red 21.4% Highest 65.7/1,000 Highest

Abortion• For those states voting “Red” in the ’04/’08

Presidential election, predicts a 8.7/10.6 per 1,000 decrease in abortions

• 27/33% of the variance in abortion explained by the model.

State Election ’08 Abortion ‘08

Delaware Blue 40.0/1,000 Highest

Wyoming Red 0.9/1,000 Lowest

Limitations on Women’s reproductive rights

• Limiting women’s reproductive rights (for many reasons it seems) results in worse health outcomes

• Poverty/Education – teen births• Religiosity – IMR, teen births • Politics – abortions, teen births

Kerala vs. other Indian States1950s• Poor women’s reproductive health outcomes• High poverty• Orthodox religious caste system2000s• Better IMR, literacy, outcomes than all of India• Dedicated political leaders willing to prioritize

public health- people centered social & economic outcomes

What can we do?• Advocate for FREE & open access to contraception• Universal access to education• Access to abortion• Vote for policy-makers who believe in science and

public health• Work with religious communities to improve care,

access & outcomes.• Concentrate on Federal/State/Local policy makers-

many decisions on local/state levels

HEALTHOGRAPHY

• Place does matter- but it can change• Continue research on the social determinants of

health • Use GIS – map it!• Advocate for change• Champion women’s reproductive health rights

Thank You!

GIS Mapping Contributor• Michael Wissner, M.S. • M.S. Geography and Environmental Systems, University

of Maryland, Baltimore County• RPCV Peru ‘05- ‘07• Fellow Alumni – Sargent Shriver Peace Worker