Women’s Health: Population Patterns and Social Determinants

Abstract

Women’s health, and what we know about it, are influenced by social factors. From the exclusion of women’s bodies in medical research, to the silence and stigma of menstruation and menopause, to the racism reflected in maternal mortality, the relevance of social factors is paramount. After a brief history of research on women’s health, we review selected patterns, trends, and inequalities in US women’s health. These patterns reveal US women’s poor and declining longevity relative to those in other high-income countries, gaps in knowledge about painful and debilitating conditions that affect millions of women, and deep inequalities that underscore the need to redress political and structural features of US society that enhance health for some and diminish it for others. We close by describing the challenges and opportunities for future research, and the promise of a social determinants of health approach for advancing a multilevel, intersectional, and biosocial understanding of women’s health.

INTRODUCTION

Women’s health refers to the physical, mental, and social well-being of women, and is a broad category of population health.¹ Women’s health, like all human health, is socially patterned. The organization of society shapes the definitions and experiences of health and illness, the distributions of death and disease, and the responses they elicit.

Our knowledge about women’s health is influenced by culture, politics, medical practices, and scientific understandings of gendered bodies. The very term “women’s health” presupposes difference. While the observation that women’s health is different from the health of others has been foundational to campaigns for the inclusion of women in biomedical research, this same logic can reify a sex/gender binary and essentialize observed variation between women’s and men’s physiology and health as natural and due to distinctive biology (Epstein 2007, Springer et al. 2012). Challenges related to group boundaries and biology are not unique to women’s health research—rather, they are common to most research that adopts a health disparities frame or that otherwise investigates whether and how health varies across social and political groups (Duster 2008, Epstein 2007). As social scientists have long observed, however, variation in health across groups need not be caused by innate differences in biology. Group differences given social meaning imbued with hierarchy and power are highly consequential for the health of human bodies.

As a group, women in the United States and elsewhere have been excluded and marginalized for centuries.² The United States has denied women access to education, the right to own property, and the right to vote. The United States has also denied women bodily autonomy through forced and coerced sterilizations and psychiatric treatments (Geller & Harris 1994, Gutiérrez & Fuentes 2010, Lawrence 2000). These policies and practices especially affected women who were racially marginalized, women who were poorer, and women with disabilities. US women today do have more economic and political power than they did in the past. Yet they remain underrepresented at the highest levels of business and government and cannot serve as clergy in many religious traditions. Furthermore, challenges to women’s bodily autonomy continue, as seen in restrictions on abortion access across US states. Women also continue to experience discrimination and violence because they are women. This history, the structural and cultural logics associated with it, and the institutional practices that perpetuate women’s exclusion, contribute to gendered scientific inquiry and gendered impacts on the body, and they provide a rationale for a focus on women’s health.

Our review centers women’s health rather than sex/gender variation in human health, although both are engaged. In centering women’s health, we highlight the importance of variation among women. Experiences of marginalization, exclusion, and erasure vary. Black and Indigenous women have experienced extreme forms of oppression often connected with White European invasion and exploitation, while other people of color, including Latinas, Pacific Islanders, and Asian women, have been subjected to significant, often anti-immigrant, forms of racial discrimination. Many of these harms are tied to settler colonialism, state-sanctioned enslavement, patriarchy, surveillance, violence, and related factors (Armstrong et al. 2018, Bridges 2011, Glenn 2015). These histories and their embedding today in structural and cultural sexisms and racisms, and other forms of social exclusion are reflected in present-day health and ongoing health disparities. In centering women’s health, we also shift the focus away from a gender difference/binary frame. Still, this review, like much of the literature we summarize, is largely a summary of cisgender women’s health.

Excellent previous reviews have covered topics such as gender and health inequalities (Read & Gorman 2010, Rieker et al. 2010), reproduction (Almeling 2015), and sexual violence (Armstrong et al. 2018). Building on this scholarship, in the sections that follow, we provide a brief background on the history of women’s health research in the United States, and then describe selected patterns, trends, and inequalities in women’s health based on literature in sociology and other fields. We then discuss the social determinants of women’s health and close with challenges and opportunities for future research.

THE RISE OF WOMEN’S HEALTH RESEARCH

In the United States, the 1970s and 1980s were a pivotal period for research on women’s health. Women’s health activism, buttressed by feminist activism, gained momentum as advocates argued that medical research overlooked many aspects of women’s health by focusing narrowly on reproductive health. They pointed to research studies and clinical trials on major health conditions that disproportionately and sometimes exclusively enrolled White men. For example, an evaluation of the efficacy of aspirin for reducing cardiovascular disease mortality was carried out on a sample of 20,000 people, all of them men (Steering Committee of the Physicians’ Health Study Research Group 1989). Advocates were concerned that the absence of women from clinical studies meant that any female-specific disease mechanisms, manifestation, and treatment would remain unknown, with all knowledge tailored to the bodies of men.

During this period, women considered of childbearing potential were routinely excluded from biomedical research because of concerns regarding safety and the possibility that their fluctuating hormones would complicate controlled study conditions (Epstein 2007). As summed up by Almeling (2020), biomedical scientists and clinicians treated male bodies as standard and female bodies as reproductive. This focus on women’s reproduction has a long history in medicine. Hippocrates and others in ancient Greece regarded a productive womb as crucial for maintaining physical and mental well-being in women; an unfulfilled womb was thought to “wander,” causing a variety of ailments and illnesses (Jones 2015). By the nineteenth century, the uterus was deemed the controlling organ, connected to the nervous system and responsible for hysteria, a catch-all term for a range of psychiatric conditions and, more generally, behavior deemed socially unfitting for women (Hunt & McNamara 2004.³ Poignantly, despite the focus on women’s reproductive organs through time, painful conditions linked to the uterus such as endometriosis received limited attention in medicine (Jones 2015).

In 1985, the Public Health Service Task Force on Women’s Health Issues confirmed what advocates had suggested: scientific data on women’s health were not being collected. They therefore called for more attention to how sex shapes heath. In 1990, the Office of Research on Women’s Health (ORWH) was established at the National Institutes of Health (NIH). Its main goals were to “address the inequities in women’s health research and to ensure that women are included in clinical studies” (Pinn 1992, p. 1921). This agenda took a giant leap forward in 1993 with the passage of the NIH Revitalization Act, which required that future clinical research on humans include “women and minority groups” and their subpopulations as participants. A follow-up 2010 Institute of Medicine report concluded that over the previous twenty years, significant progress had been made on some conditions, including breast cancer, cardiovascular disease, and cervical cancer, while few advances had been made in other areas, such as autoimmune diseases, unintended pregnancy, and maternal morbidity and mortality (Inst. Med. 2010).

In 2014, Janine Clayton, director of the ORWH, and Francis Collins, the NIH director, celebrated the achievement of gender parity in NIH clinical research (Clayton & Collins 2014). They then called on researchers to balance sex in cell lines and preclinical animal studies as well, as such studies underpin the development of clinical trials in humans. Today, the NIH continues to emphasize the importance of gender inclusion and sex as a biological variable in clinical research. The NIH is also engaged in efforts to improve health among sexual and gender minority populations, adopt intersectional and structural approaches to health disparities, improve maternal mortality and rates of chronic disease among women, and more. The ORWH remains a key advocate for advancing a women’s health agenda across institutes at the NIH.

Nonetheless, as is regularly noted by the ORWH and women’s health researchers, challenges persist. A 2021 study concluded that research on diseases that disproportionately affect men are more likely to be overfunded by the NIH, while those that primarily affect women are more likely to be underfunded relative to disease burden in the population (Mirin 2021).

THE STATE OF WOMEN’S HEALTH

A typical woman born in the United States today can expect to live just over 81 years (Natl. Cent. Health Stat. 2021). Approximately 65 years, or four-fifths of her life, would be lived disability-free, without activity limitations due to poor health (Crimmins et al. 2016). At ages 65 and older, she would be living with at least two chronic health conditions, such as cardiometabolic disorders (high blood pressure, high cholesterol, diabetes), respiratory conditions, osteoarthritis or inflammatory joint problems, and mood or anxiety disorders (Buttorff et al. 2017). She would be likely to die of either heart disease or cancer (CDC 2017). While every woman’s health will follow a different trajectory, we describe average women’s health in the United States with a set of statistics to benchmark it relative to women in other high-income countries, as well as to compare it to that of men. Such comparisons are used frequently to advocate for a focus on women’s health as a category of population health as well as to inform scientific questions and inferences regarding women’s health.

US Women’s Life Expectancy in Global and Historical Context

The health of women in the United States compares poorly to the health of women in other high-income countries. Life expectancy among US women ranked in place 30 out of 36 Organisation for Economic Co-operation and Development (OECD) countries in 2017 (OECD 2019), despite the United States spending more per capita on healthcare than any other OECD nation (WHO 2021). US women were expected to live 6 years fewer (81.1) than women in Japan (87.3).⁴ When considering potential years of life lost due to premature mortality, the United States ranked in second-last place among OECD nations (OECD 2021b). This reflects the larger proportion of girls and women who die young in the United States, when deaths are more likely to be preventable, than in other countries.

Concern for the health of US women has mounted in recent years as improvements in life expectancy have stalled (Crimmins & Zhang 2019; Natl. Acad. Sci. Eng. Med. 2021; Natl. Res. Counc. 2011, 2013). US women’s life expectancy increased by an average of 4.6 years per decade over the first half of the twentieth century, from 48.3 years in 1900 to 71.1 in 1950 (Bastian et al. 2020). Over the next 60 years, gains slowed to an average of 1.6 years per decade, reaching 81.0 by 2010 and changing little since then. While gains in women’s life expectancy would be expected to be larger over the first half of the twentieth century due to major reductions in mortality from infectious disease, the slowdown has been more pronounced in the United States than in other high-income countries (Crimmins & Zhang 2019; Natl. Acad. Sci. Eng. Med. 2021; Natl. Res. Counc. 2011, 2013). As a result, and as shown in Figure 1, the gap in life expectancy between women in the United States and those in other high-income countries has increased (OECD 2021a).

Figure 1.

Life expectancy at birth among US women and women in other OECD countries, 1980–2019. Orange dots indicate life expectancy in the United States. Gray dots indicate life expectancy in 22 other OECD countries (the other original OECD countries, excluding Turkey, plus early joiners including Japan, Finland, Australia, and New Zealand). Data are from OECD (2021a).

Several reports have been compiled over the past decade to document and explain trends in life expectancy for the US population (Natl. Acad. Sci. Eng. Med. 2021; Natl. Res. Counc. 2011, 2013). The most recent report finds that life expectancy actually declined between 2014 and 2017 for working-aged Americans, a phenomenon not seen since the 1918 influenza pandemic (Natl. Acad. Sci. Eng. Med. 2021). While increasing midlife mortality was initially detected among middle-aged non-Hispanic White people, and women in particular (Case & Deaton 2015, Gelman & Auerbach 2016), these troubling patterns have since been observed for other population groups as well (Natl. Acad. Sci. Eng. Med. 2021).

There is no simple explanation for these patterns. The lagged effects of smoking and the obesity epidemic appear to play large roles in the gap in life expectancy between women in the United States and elsewhere (Natl. Res. Counc. 2011). Rising midlife mortality within the United States, meanwhile, stems in part from increasing rates of death related to drugs, alcohol, and suicide, and to slowing improvements in cardiometabolic disease mortality (Natl. Acad. Sci. Eng. Med. 2021). Structural factors, such as lax regulations on pharmaceutical industries, weak occupational safety standards that lead to high levels of chronic pain, the collapse of certain industries, and more, underlie these proximal explanations.

Mortality and Life Expectancy

Causes of death provide an overall profile of population health. Among US women, the five leading causes of death in 2017 were chronic diseases, most notably heart disease (21.8%) and cancer (20.7%), followed by lung disease (6.2%), cerebrovascular disease (6.2%), and Alzheimer’s disease (6.1%) (CDC 2017). Over the past several decades, mortality rates among women declined dramatically for heart and cerebrovascular diseases, while deaths from lung disease increased considerably (Ma et al. 2015), likely due to the lagged effects of tobacco use (Thun et al. 2013). For men, the leading causes of death in 2017 matched those of women with the exception of Alzheimer’s. Alzheimer’s disease (2.6%) was displaced by accidents, which caused 7.6% of deaths among men compared with 4.4% among women (CDC 2017).

While the leading causes of death are similar for women and men, average life expectancy at birth differs markedly. A typical woman born in the United States in 2018 could expect to live 5 years longer (81.2 versus 76.2 years) than a typical man (Natl. Cent. Health Stat. 2021). Since at least 1900, US women have held an advantage in life expectancy compared with men (Bastian et al. 2020). The difference in life expectancy between women and men has declined, however, since its peak at more than 7 years from the mid-1960s through the mid-1980s, as life expectancies have improved more slowly for women than for men (Bastian et al. 2020).

Inequalities in Life Expectancy and Mortality

Life expectancy also varies significantly among women by their social locations of race and education. For more than a century, life expectancy for White women in the U.S. has been higher than that for Black women. Gaps in life expectancy between White and Black women have narrowed over time but remain substantial at nearly 3 years in 2017 (Bastian et al. 2020). In 2017, life expectancy at birth was 81.0 years for non-Hispanic White women and 78.1 years for non-Hispanic Black women (Natl. Cent. Health Stat. 2021). Life expectancy among Hispanic women was higher than for non-Hispanic White or Black women, at 84.3 years (Natl. Cent. Health Stat. 2021). Statistics are not as readily available for other ethnoracial groups (Williams 2002). Recent evidence suggests that life expectancy is high among Asian and Pacific Islander (API) women overall (88.7 years), although with differences across ethnic groups (Baluran & Patterson 2021). Meanwhile, life expectancy may be poor among American Indian and Alaska Native (AIAN) women (Abbasi 2018).

While racial disparities in women’s life expectancy have lessened in recent years, differences by education have widened (Meara et al. 2008, Montez et al. 2011, Montez & Zajacova 2013b, Sasson 2016). This is because since the 1980s, more-educated women have experienced larger gains in life expectancy than less-educated women. This pattern is apparent among both White and Black women. It has also been observed among men.

Analyzing data from the National Vital Statistics System, Sasson (2016) finds that between 1990 and 2010, life expectancy at age 25 declined by 3.1 years for non-Hispanic White women with 0–11 years of schooling (Figure 2). Over the same period, it rose by 3.7 years for White women with 16 years of schooling or more, ultimately increasing the educational disparity in life expectancy from 2.5 years in 1990 to 9.3 years in 2010. The educational disparity among non-Hispanic Black women also grew between 1990 and 2010, from 1.9 years to 4.7, although life expectancy increased for Black women with both low and high education. While patterns among low-educated White women have generated alarm, life expectancy for low-educated White women was no poorer than that among low-educated Black women in 2010. Meanwhile, racial disparities in life expectancy between White and Black women with more education remained substantial in 2010.

Figure 2.

Life expectancy at age 25 among US women by race and education, 1990–2010. Low education indicates 0–11 years of education, and high education indicates 16 or more years. Data are from Sasson (2016).

The declining economic circumstances of less-educated adults may be central to understanding growing educational gradients in mortality and morbidity (Montez & Zajacova 2013a) as well as stagnating improvements in Americans’ longevity more generally (Natl. Acad. Sci. Eng. Med. 2021). Although deaths due to economic hardship are not as straightforward to identify as those related to tobacco use, the term “deaths of despair” has been used to describe those stemming from the increasingly bleak economic circumstances facing less-educated Americans, including declining wages and increasing unemployment (Case & Deaton 2020). Indeed, the number of deaths from suicide, alcohol-related liver disease, and drug overdoses has risen to unprecedented levels over several decades, particularly among White people who did not finish high school. Drug overdoses have risen particularly rapidly among less-educated White women, among whom they are estimated to account for 11.9% of the growing disparity in life expectancy between the most and least educated groups between 1992 and 2011 (Ho 2017).

Rates of morbidity and mortality among low-educated adults vary substantially across US regions and states, suggesting that low education has different implications for health in different sociopolitical contexts (Montez et al. 2017b, 2019a,b). For US women, the educational gradient in mortality grew the least between 1986 and 2006 in the Northeast, as women there (particularly White women) did not experience the same increase in mortality as women in other regions of the country (Montez & Berkman 2013, Montez et al. 2019a). More research is needed to identify why this is the case, although emerging evidence suggests that income inequality, protections for low-income workers, and taxes on tobacco products may be relevant and that more liberal state governments may be associated with better population health (Montez et al. 2016, 2017a, 2020).

Health and Illness

Women’s longevity advantage compared with men is not accompanied by an overall health advantage. Women are more likely than men to report activity limitations, a key measure of disability (Crimmins et al. 2019, Freedman 2018, Freedman et al. 2016). An analysis of data from the National Health and Aging Trends Study, for example, shows that just 23.7% of women ages 65 and older are “fully able” to conduct basic self-care and mobility activities, compared with 36.6% of men (Freedman 2018). Women are also more likely to be considered frail, which is predictive of subsequent falls, hospitalization, and death (Bandeen-Roche et al. 2015). Furthermore, women are more likely than men to report chronic pain, the prevalence of which has risen for all age groups in recent decades (Zajacova et al. 2021).

Several chronic conditions that are nonfatal but potentially debilitating, such as mood and anxiety disorders, are prevalent among women (Crimmins et al. 2019, Rieker & Bird 2005). Data from the National Health and Nutrition Examination Survey show that about 1 in 10 adult women (10.4%) experience depression, nearly twice the rate among men (5.5%) (Brody et al. 2018). Gender variation in depression appears to emerge around puberty and peak in adolescence, remaining evident throughout the adult lifespan (Salk et al. 2017).

Autoimmune diseases are also especially common among women. An estimated 6.4% of women are affected by one or more autoimmune disease, compared with 2.7% of men (Hayter & Cook 2012). Women are overburdened by autoimmune thyroid disease, systemic lupus, Sjogren’s syndrome, rheumatoid arthritis, multiple sclerosis, and more (Hayter & Cook 2012, Jacobson et al. 1997). Autoimmune conditions occur when the immune system mistakenly attacks healthy tissue, often causing pain, fatigue, and other disease-specific symptoms. Historically, these symptoms, which also accompany other female-dominated conditions (e.g., chronic fatigue, fibromyalgia, endometriosis), were largely dismissed as psychosomatic and characteristic of hysteria (Cleghorn 2021, Dusenbery 2018). Still today, sufferers are frequently misdiagnosed or dismissed by doctors. A mixed methods study of an online sample of 233 adults with systemic lupus, for example, found that patients waited years to receive an appropriate diagnosis (Sloan et al. 2020). Three in four were misdiagnosed at least once, and nearly half of those who were misdiagnosed were told their symptoms were psychosomatic or medically unexplained. Many of those with autoimmune conditions struggle to manage their chronic pain and fatigue even after diagnosis, and cures remain elusive. The reasons for the higher prevalence of autoimmune conditions in women remain poorly understood, although sex-specific hormonal and genetic factors are assumed to be important (Libert et al. 2010, Ngo et al. 2014).

Studies evaluating biological markers of physiological function suggest that women also carry a higher inflammatory burden, on average, than men (Crimmins et al. 2019, Yang & Kozloski 2011). However, in many contexts, including the contemporary United States, women have better cardiometabolic risk factor profiles than men, with lower rates of high blood pressure, diabetes, metabolic syndrome, and diagnosed cardiovascular disease (Crimmins et al. 2019, Rieker & Bird 2005, Yang & Kozloski 2011). This may be why heart disease is often perceived as a man’s disease and why its unique presentation, prevention, and treatment in women was unrecognized for so many years, despite also being the leading cause of death for women (Mosca et al. 2011).

Indeed, gender bias in medicine presents an ongoing challenge for women’s health. Numerous studies show that women regularly receive different diagnoses and recommended courses of treatment than men with similar symptoms or conditions, to the detriment of women’s wellbeing. For example, a vignette study found that when patient actors presented with symptoms of coronary heart disease, physicians expressed more diagnostic uncertainty for women than men, and were more likely to believe symptoms resulted from mental health conditions for women (Maserejian et al. 2009). Similarly, a study of emergency department patients found that women experiencing stroke were more often initially misdiagnosed than men (Newman-Toker et al. 2014) and women have been shown to experience longer diagnostic intervals for various cancers than men (Din et al. 2015). Women are also less likely to receive pain medications than are men (Chen et al. 2008), possibly because pain is minimized and often perceived as psychosomatic in women (Zhang et al. 2021).

SEXUAL AND REPRODUCTIVE HEALTH

Although reproductive health all but defined women’s health until the 1990s (Weisman 1998), aside from a handful of topics, evidence-based medical science specific to women’s sexual and reproductive health is notably sparse.

Menstruation and Menopause

Menstrual bleeding, experienced by roughly half of all people, lasts for about 40 years, starting around the age of 12 and stopping around the age of 51 (Forman et al. 2013, Gold et al. 2001, Hoyt et al. 2020). Considerable scientific interest has focused on the timing of the start and end of menstrual bleeding. In the United States and elsewhere, puberty and menarche are occurring at younger ages than in the past (Martinez 2020, McDowell et al. 2007). This pattern has raised concerns, as earlier puberty/menarche has been linked with a range of adverse outcomes, including cardiovascular disease and all-cause mortality, although it is not clear whether the timing of menarche is a contributor to, or an indicator of, health (Charalampopoulos et al. 2014, Hoyt & Falconi 2015, Prentice & Viner 2013). As with menarche, studies find that the earlier onset of menopause is associated with poor health outcomes (Muka et al. 2016, Shuster et al. 2010). Early and premature menopause, defined as menopause beginning prior to ages 45 and 40, respectively, can occur naturally or be induced by medical procedures and treatments that have become more common over time (e.g., oophorectomy following hysterectomy, or chemotherapy) (Shuster et al. 2010).

Symptoms associated with menopause, including hot flashes, night sweats, minor memory lapses, sleep difficulty, vaginal dryness, and decreased libido, present considerable challenges for some (Pinkerton 2020). Hormone replacement therapy (HRT) is currently the most effective pharmaceutical treatment for these symptoms (Pinkerton 2020), although its safety has been the subject of intense debate (Lobo 2013). Clinical trials of HRT for the Women’s Health Initiative were halted early, with the risks of HRT claimed to outweigh its benefits for the prevention of chronic disease (Writing Group for the Women’s Health Initiative Investigators 2002). Following this announcement, use of HRT declined precipitously (Lobo 2013), but more recently, investigators have clarified that HRT is likely safe and beneficial for healthy women in the early stages of menopause (Manson et al. 2013, Pinkerton 2020). Some say the reason alternative treatments were not developed in the midst of this debate is that menopause is considered a natural physiological process. Others ask whether an event causing similar disruption for men—even one considered natural—might not generate more interest in developing pharmaceuticals to manage the effects.

Overall, menstruation receives limited attention despite its social significance and implications for health and well-being. For centuries, in the United States and globally, menstruation has fueled misogynistic arguments justifying women’s exclusion from social spaces including, for example, schools and workplaces (Cleghorn 2021, Critchley et al. 2020). Stigma and silence persist in and out of science, though recent developments are promising. In 2018, the NICHD noted the limited scientific attention menstruation has received and convened a meeting to identify research gaps and opportunities in menstruation science. In addition, menstrual equity and period poverty movements are expanding in the United States to end the silence on menstruation and promote access to menstrual products and management as a right, which has contributed to numerous US states and cities enacting legislation that exempts menstrual products from sales tax (Critchley et al. 2020, Sommer & Mason 2021, Weiss-Wolf 2017).

Contraception and Abortion

Roughly 85% of women in the United States have given birth to at least one child by their late forties. However, they are having fewer children than in the past and doing so at older ages. The total fertility rate among US women reached a record low in 2020, with an expected 1.64 children per woman (Hamilton et al. 2021), while the average age at first birth increased from 24.9 in 2000 to 27.0 years in 2019 (Martin et al. 2021, Mathews & Hamilton 2016). A report from the Guttmacher Institute estimates that many US women spend about three decades of their lives attempting not to become pregnant (Sonfield et al. 2014). Most women rely on contraception, and especially sterilization, oral contraceptive pills, and long-acting reversible contraceptive methods, including intrauterine devices (Daniels & Abma 2020). Access to contraception is an important aspect of women’s reproductive autonomy (Potter et al. 2019). Unfortunately, in many places across the United States and for marginalized people in particular, access to contraception remains suboptimal, owing in part to state policymakers’ decisions regarding the appropriate use of Medicaid funds (Stevenson et al. 2016).

Although most women report having used some form of contraception in their lifetime, unintended pregnancy is common, comprising an estimated 45% of all pregnancies in 2011 (Finer & Zolna 2016). Approximately 42% of these pregnancies were terminated through abortion (Finer & Zolna 2016). Elsewhere, it has been estimated that one in four US women will have an abortion by the age of 45 (Jones & Jerman 2017). Abortion is a critical component of women’s healthcare, as well as reproductive autonomy (Potter et al. 2019). Although abortion is legal at the federal level, its protection is currently under review by the Supreme Court, and its access is severely restricted in many US states, compromising women’s mental and physical health and social and economic outcomes (Foster et al. 2018, Gerdts et al. 2016). While those in favor of restrictions on abortion often cite concerns over women’s health, induced abortion is incredibly safe (Zane et al. 2015), with the alternatives—self-managed abortion (Ralph et al. 2020) or carrying a pregnancy to term—involving far greater risks of life-threatening complications and death (Stevenson 2021).

Maternal Morbidity and Mortality

About 700 people in the United States die from pregnancy-related causes each year—half of them postpartum—and about 6 in 10 of such deaths are preventable (Petersen et al. 2019a). The rate of maternal mortality in the United States compares poorly to that of other high-income countries and has risen over the past few decades (Kassebaum et al. 2016, MacDorman et al. 2016). The leading causes include cardiovascular conditions, infection, and hemorrhage (Petersen et al. 2019a). Homicide is also among the leading causes of death for pregnant and postpartum women in the United States (Horon & Cheng 2005, Wallace et al. 2016). In Louisiana in 2016–2017, homicides outnumbered deaths from any single obstetric cause among pregnant and postpartum women (Wallace et al. 2020).

A clear example of racism in women’s health can be found in reproductive and maternal health (Chinn et al. 2020, Eichelberger et al. 2016, Howell 2018). Pregnancy-related mortality rates (i.e., pregnancy-related deaths per 100,000 live births) from 2007 to 2016 are about three times higher among Black women (40.8) compared with White women (12.7) (Petersen et al. 2019b). Rates are also elevated among AIAN women (29.7), but not among Hispanic (11.5) or API (13.5) women. As shown in Figure 3, these disparities are evident within socioeconomic subgroups. For example, among college graduates, Black women are 5.2 times more likely to die from pregnancy-related complications than White women. Other studies show that similar patterns persist with respect to severe maternal morbidity, with Black, Hispanic, and AIAN women experiencing major complications at higher rates than White women (Gray et al. 2012; Howell et al. 2016, 2017). Racism contributes in myriad ways. A growing body of research suggests that differential healthcare access and hospital quality before, during, and after delivery contribute to these patterns (Howell 2018). Other research highlights differential care. Surveys of women show that mistreatment in maternity care (e.g., being ignored or yelled at) is common overall, but even more so among women of color (Vedam et al. 2019).

Figure 3.

Pregnancy-related mortality rates among US women by race and education, 2007–2016, as available. Pregnancy-related mortality rates reflect pregnancy-related deaths per 100,000 live births. Data are from Petersen et al. (2019b)

Figure 3 also shows that maternal mortality rates generally decline with education. Across all women, the number of pregnancy-related deaths per 100,000 live births between 2007 and 2016 was 21.6 for those who did not complete high school, 27.4 for those with a high school diploma, 16.4 for those with some college education, and 10.9 among those who graduated college (Petersen et al. 2019b). The educational gradient in maternal mortality is largest for non-Hispanic White women, for whom the rate is 3.2 times greater for the least educated compared with the most educated women (Petersen et al. 2019b). Still, educational gradients pale in comparison to racial disparities. Consider that the pregnancy-related mortality rate for Black college graduates (40.2) is nearly double that of White women who did not finish high school (21.6) (Petersen et al. 2019b).

Postpartum Care

Postpartum care in the United States is an overlooked aspect of women’s health (Cheng et al. 2006). In states that have not expanded Medicaid, most publicly insured women—who are disproportionately women of color and poor—lose access to healthcare just six weeks postpartum. Meanwhile, risk of pregnancy-related complications as well as postpartum depression remain elevated up to a year after birth, with more than 1 in 10 maternal deaths occurring more than six weeks postpartum (Petersen et al. 2019a). Studies suggest that expanding paid leave may increase postpartum care (Steenland et al. 2021), while expanding insurance coverage to one year postpartum may reduce maternal morbidity and mortality overall, as well as racial disparities in maternal outcomes (Gordon et al. 2020, Luther et al. 2021).

Cervical Cancer and Endometriosis

Cervical cancer is preventable and treatable, and it disproportionately affects women of color. In 2018, about 300,000 women were living with cervical cancer in the United States (Natl. Cancer Inst. 2021). Most cervical cancer is due to human papillomavirus (HPV), a highly prevalent sexually transmitted infection. While the HPV vaccine could generate improvements in women’s health for years to come, its uptake in the United States has been poor relative to other high-income countries (Bruni et al. 2021). Just half of US adolescents were up to date on their HPV shots in 2018 (Walker 2019). Rates are higher among women than men, among non-Hispanic White people than Black or Hispanic people, and among those with health insurance compared with the uninsured (Boersma & Black 2020, Walker 2019). Similarly, Pap screening tests have been shown to drastically lower the incidence of cervical cancer; however, millions of women are unscreened or underscreened. They are disproportionately uninsured women, immigrant women, and women without a usual source of healthcare (Gaffney et al. 2018). The incidence of cervical cancer is 30% higher and mortality rates are 75% higher among non-Hispanic Black women compared with non-Hispanic White women, in part because Black women are diagnosed at later stages of disease (DeSantis et al. 2019). Finally, though incidence of cervical cancer has declined significantly since the introduction of Pap tests, 5-year relative survival rates have not improved (68.3% in 1975 and 69.1% in 2013) (Natl. Cancer Inst. 2021).

Endometriosis is a painful and poorly understood condition affecting approximately 10–15% of women of childbearing age (Buck Louis et al. 2011, Parasar et al. 2017). Endometriosis occurs when tissue similar to the lining of the uterus grows elsewhere in the body; the tissue may swell and become inflamed, causing major discomfort and sometimes infertility. On average, diagnosis occurs 6.7 years after symptom onset (Nnoaham et al. 2011). This is in part because women wait to seek help, perhaps believing their symptoms are a normal part of menstruation, and in part because when women do seek help, their symptoms are minimized and dismissed or misattributed by medical professionals to other conditions, such as irritable bowel syndrome (Culley et al. 2013). There is currently no noninvasive way to confirm the presence of endometriosis, besides symptomology, and it is likely underdiagnosed, especially among women with reduced access to care. Some cases of endometriosis can be kept at bay with hormonal birth control, although others require surgery. It is astonishing that a condition that affects so many women, with major implications for quality of life (Culley et al. 2013, Nnoaham et al. 2011), remains so poorly understood.

VIOLENCE

Violence is central to US women’s health. By one estimate, the rate of death by homicide among women in the United States is over four times the rate across other high-income countries, due in large part to firearm-related incidents (Grinshteyn & Hemenway 2019). Homicide is a leading cause of death for girls and young women overall, and for pregnant or postpartum women in particular (CDC 2017; Horon & Cheng 2005; Wallace et al. 2016, 2020). According to data from 18 states in the National Violent Death Reporting System, non-Hispanic Black women and AIAN women experienced the highest homicide rates between 2003 and 2014 (4.4 and 4.3 per 100,000 population, respectively), followed by Hispanic (1.8), non-Hispanic White (1.5), and API women (1.2) (Petrosky 2017). Approximately half of female homicides are committed by current or former intimate partners (Jack et al. 2018, Petrosky 2017).

Relatedly, intimate partner violence, which may involve physical or sexual abuse, stalking, or psychological aggression between current or former spouses or dating partners, is extremely common. The Centers for Disease Control and Prevention’s National Intimate Partner and Sexual Violence Survey from 2015 finds that 30.6% of women have experienced physical violence from an intimate partner in their lifetime, with 21.4% experiencing severe physical violence (Smith et al. 2018). Sexual violence between intimate partners, which includes rape, coercion, and other unwanted sexual contact, is experienced by 18.3% of women.

The same survey finds that 43.6% of US women experience some form of contact sexual violence—whether by a partner or someone else—in their lifetime (Smith et al. 2018). The prevalence of rape and attempted rape is particularly alarming, with one in five women (21.3%) being assaulted in her lifetime.

TRANSGENDER AND GENDER NONCONFORMING POPULATIONS

The meaning of “women’s health” is changing over time as cultural and scientific understandings of sex and gender identity and expression have changed. Some scholars suggest that the health of transgender and gender nonconforming people should be included under the umbrella of women’s health (Kattari et al. 2020). Estimates suggest that between 1 and 1.4 million US adults are transgender or gender nonconforming. (Crissman et al. 2017, Flores et al. 2016b, Meerwijk & Sevelius 2017, Zhang et al. 2020). Transgender and gender nonconforming populations are highly heterogeneous in their gender identities and transition experiences (Meyer et al. 2021). In the United States, transgender people are disproportionately non-White and socioeconomically marginalized compared with cisgender people (Crissman et al. 2017, Flores et al. 2016a, James et al. 2016).

Research on health in transgender and gender nonconforming populations is underfunded and covers a relatively narrow terrain (Coulter et al. 2014). A systematic review of research on health among gender nonconforming populations globally shows that studies tend to focus on mental health; sexual health and HIV in particular; substance use; violence and victimization; and stigma and discrimination (Reisner et al. 2016). In the United States, for example, numerous studies document exceedingly high rates of depression, anxiety, and other markers of distress among transgender adults. Among respondents to the 2015 U.S. Transgender Survey, 39% experienced serious psychological distress in the past month, compared with roughly 5% of the US population overall (James et al. 2016). These outcomes are related to stigma, discrimination, and violence, and may also be related to socioeconomic marginalization faced by many trans people (James et al. 2016). While existing research highlights critical concerns for transgender and gender nonconforming people, research on a broader range of health outcomes is needed. Inclusion, including improved measurement of sexuality, sex assigned at birth, and gender identity in data collection, is also essential (Westbrook et al. 2021). Notably, data collection efforts are underway to address this important information gap. The Generations and TransPop Studies have collected the first LGBTQ population-based national data that include sub-populations of transgender people, non-transgender sexual minority women, and non-transgender sexual minority men (Meyer et al. 2021).

THE SOCIAL DETERMINANTS OF WOMEN’S HEALTH

Women’s health, and what we know about it, are influenced by social factors. From the exclusion of women’s bodies in medical research, to the silence and stigma of menstruation and menopause, to the racism reflected in maternal mortality, the relevance of social factors is paramount. It follows that social science research is critical to improving the health and well-being of women and to advancing health equity. In this section, we describe the widely applied social determinants of heath, a flexible multilevel biosocial framework, as a tool for advancing an integrative approach for research on women’s health (Harris 2010).

A social determinants of health perspective starts from the assumption that health is shaped significantly by nonmedical factors (Braveman et al. 2011). These nonmedical factors include individual characteristics, such as education and income, as well as upstream or macro-level factors such as the labor market, schools, healthcare systems, legal systems, institutionalized practices, and ideologies, all of which further enable or constrain health (McKinlay 1975). An additional meso level is situated between the individual level and macro level and focuses on the proximate settings in which people live their lives—including communities, workplaces, schools, and families—as well as relational factors, such as the interpersonal interactions that take place within and across these settings, all of which are fundamental for well-being (Schnittker & McLeod 2005, Short & Mollborn 2015).

A social determinants approach incorporates biosocial processes, and these can be used to elaborate how features of society get under the skin to shape life course health (Short & Mollborn 2015). Example biosocial processes include embodiment and embedding. Embodiment refers to the process of the biological incorporation of societal and ecological context from the physical and social worlds in which we live (Krieger et al. 2012). Embedding emphasizes the developmental aspects of embodiment by focusing on the timing of environmental exposures, with an emphasis on exposures that occur early in the life course, especially during sensitive periods in brain or biological development, and with potential to shape lifelong outcomes through social and biological mechanisms, sometimes over generations (Hertzman 2013). Recent scholarship linking and harmonizing longitudinal population data to provide coverage over the life course suggests previously unidentified mechanisms linking social relationship patterns with health, offering one illustration of this promising direction (Yang et al. 2016).

Societal structures that, together, privilege or oppress people are among the most powerful of forces shaping life expectancy and health. Amid the backdrop of unprecedented economic inequality, educational disparities in health are growing, perhaps especially among women, such that college-educated women are living longer than ever while those with less than a high school diploma have seen stagnating improvements or even declines. The stark racial disparities in women’s health across outcomes underscore racism as a fundamental cause of inequalities in health (Phelan & Link 2015). Bonilla-Silva (2015) describes racial structure as a network of social relations at social, political, economic, and ideological levels that shape the life chances of the various races (Bonilla-Silva 2015). A social determinants approach might be used to conceptualize and model aspects of this shaping across macro, meso, and micro levels, including aspects of embodiment. Recent work that describes stress-related biological mechanisms linking interpersonal racism to life course health trajectories among African Americans provides an example (Goosby et al. 2018). In a parallel way, research on the gender system illustrates how state-level measures of sexism are associated negatively with physical health for women and men, including through meso-level relational dynamics (Homan 2019). Importantly, systems of oppression such as sexism, racism, and classism intersect and overlap (Crenshaw 1989, McCall 2005). As argued years ago by Black feminist scholars, these overlaps are essential for understanding life chances and health (Collins 2002) and will be critical for future research on disparities in women’s health.

CHALLENGES AND OPPORTUNITIES IN RESEARCH ON WOMEN’S HEALTH

While a social determinants approach offers promise for advancing an integrative science on women’s health, numerous conceptual and methodological challenges will need to be addressed. Based on our review of the literature, we suggest five:

1. The conflation of women’s health and reproductive health. Although progress has been made, this challenge remains. Not all health in women is related to reproduction. And reproductive health is a concern of all people. Chronic diseases are the number one killers of women. Opportunity exists to move beyond the siloed physiological system-by-system approach and to instead consider dynamic relationships between physiological systems, including the interplay between reproductive and other organ systems.

2. Emphasis on (dichotomized) sex differences. Research related to women’s health has largely focused on sex/gender differences in health, and especially how health varies between men and women. This focus emphasizes the gender binary and overlooks the fluidity of gender and the experiences of gender nonconforming people. It also effectively anchors explanations for health disparities at the individual level, a challenge discussed below. Opportunity exists for more detailed attention to variation among women, for defining and modeling sex/gender as continuous and changing, and for more inclusive science.

3. Essentialist frames that default to biological explanation. In research on sex/gender differences in health, any variation that remains after accounting for individual-level variables is frequently interpreted as resulting from underlying sex-based biology. For example, remaining variation may be attributed to (usually unmeasured) hormones or chromosomes. Opportunity exists to develop conceptual models that more fully engage biosocial explanations and mechanisms. Longitudinal studies that feature variation in samples across place and time, allowing regional and cohort comparisons, would invite deeper investigation of biosocial interplay.

4. Inadequate incorporation of structural, physical, cultural, and interactional dynamics. Bodies do not exist apart from their surroundings. Contextual factors are frequently absent, inadequate, or static in sources of detailed health data. Opportunity exists to conceptualize and measure dynamic multilevel context, including the contextual and relational aspects of gender systems, and for linking this context to population health surveys or clinical health data.

5. Limited incorporation of intersectional approaches. Women are situated differently in multiple systems of oppression that overlap and are mutually constitutive. Too often, race, class, gender, sexuality, ability, and the other factors that help to define a person’s social location are conceptualized and measured separately, and at the individual level. Opportunity exists to engage intersectional theory more fully and to measure and integrate a multilevel, intersectional context to advance understanding of the structural factors that shape health and health disparities.

CONCLUSIONS

The state of women’s health in the United States is poor. Women in the United States are doing less well than women in other high-income countries on multiple measures of health, and health disparities are large and, in some cases, growing. Why are US women doing less well than women in other high-income countries? And what sustains their health disparities? U.S. women, on average, are attaining higher levels of education than in the past, and are achieving greater political and governmental representation. And yet, population health patterns reveal slowed, stalled, and sometimes worsening health for women, with deep disparities across numerous indicators.

The need to understand and address these patterns is great. The contribution of social structures, and the social relations that define them, is undeniable. Yet, research on women’s health is largely biomedically oriented. With the growing wealth of data on social determinants, social scientists, including sociologists, have much to contribute. We outline how a social determinants approach provides a way to examine women’s health in a dynamic, multilevel framework that integrates cultural and structural factors, interactional dynamics, and biosocial mechanisms. We observe that numerous efforts adopt conceptual and empirical approaches that model complex causality and dynamic systems.

Much research on women’s health, including the studies we summarize, presumes male-female differences, with a heavy reliance on essentialist paradigms that focus on natural difference. This occurs despite widespread acknowledgment of the primacy of social factors as fundamental causes of health (Link & Phelan 1995). The case for integrating social and biomedical factors shaping gender variation in health has been advanced expertly for years (Read & Gorman 2010, Rieker & Bird 2005). The next generation of research on women’s health will need to reject essentialist frames that relegate unexplained variation to fixed innate characteristics, without rejecting biological variation in all its forms. Considerable scholarship documents how histories, experiences, and exposures are embodied and reflected in physiology, and how this physiology in turn shapes social experiences. Women’s health trajectories reflect the intertwining of biological and social factors over the life course.

Modeling the unfolding of women’s health over the life course as the interplay between social and biological, such that each depends upon and shapes the other, has already begun. At least three challenges remain and fall squarely in sociology’s corner: how to conceptualize and measure what it means to live in a multi-faceted gendered world (patriarchal, misogynist, sexist, heteronormative, cis-centric, etc); how to link this gendered world with other systems of oppression, including racism, classism, and ableism to represent more fully the contexts individuals experience more fully by situating individuals in context; and how best to model the relational mechanisms that connect the distal factors, the upstream structures that shape inequality and lived experiences, to the sex/gender-sensitive processes of embodiment that recognize agency, the inadequacy of sex/gender binaries, and the bidirectionality of relationships inherent in systems. Making progress in any of these areas would move us closer to a social science of women’s health. It would also promote health and health equity by providing a better understanding of the myriad factors that shape individual, intergenerational, and population health.