[Journal article] What the Agency for Healthcare Research and Quality Forgets to Tell Americans about How to Protect Their Sexual and Reproductive Health
From the January/February 2015 journal article abstract
If there is one thing that health care experts seem to agree on, it is the importance of preventive care. Anything that can help the American public to do a better job of understanding, accessing, and affording effective preventive care and thereby helping them to avoid potential threats to their health should be indisputably a good thing for individuals, families, and society.
Recommendations for the public about what preventive care services an individual might need at different points in his or her life can be one important tool in this tool box, and that goes double for recommendations that speak with the imprimatur of the U.S. Department of Health and Human Services (DHHS). So, a series of fact sheets on “staying healthy” from the Agency for Healthcare Research and Quality (AHRQ)—a branch of DHHS devoted to evidence-based improvements to the provision of U.S. health care—should be a welcome and valued resource (Agency for Healthcare Research and Quality (AHRQ), 2014a, Agency for Healthcare Research and Quality (AHRQ), 2014b).
In this light, it is disappointing to find the AHRQ fact sheets falling short of the mark in some critical ways related to their recommendations on sexual and reproductive health care. The four fact sheets—for women of all ages, women at age 50 and older, men of all ages, and men at age 50 and older—contain a wealth of good advice about screenings and preventive medicine that a patient might need. However, they leave out many effective sexual and reproductive health-related preventive services—perhaps most notably any mention of contraceptive services and supplies—that have been endorsed by other agencies in the DHHS and by the medical establishment more broadly, and that have been promoted through the Affordable Care Act’s (ACA) requirements for private health plans to cover preventive services without patient out-of-pocket costs (HealthCare.gov, 2014, Sonfield, 2012). The AHRQ fact sheets compound those oversights by seeming to imply that they embody the sum total of DHHS’s preventive care recommendations, when in reality they seem to be based almost exclusively on the recommendations of a single body, the U.S. Preventive Services Task Force.
From the 6 February 2014 ScienceDaily article
Summary:Despite the fact that heart disease is the leading cause of death for both men and women in the U.S., about three-quarters (74 percent) of Americans do not fear dying from it, according to a recent survey.
Despite the fact that heart disease is the leading cause of death for both men and women in the U.S., about three-quarters (74 percent) of Americans do not fear dying from it, according to a recent survey from Cleveland Clinic.
Conducted as part of its “Love Your Heart” consumer education campaign in celebration of Heart Month, the survey found that Americans are largely misinformed about heart disease prevention and symptoms, and almost a third (32 percent) of them are not taking any proactive steps to prevent it. Even among those Americans with a family history of the disease (39 percent), who are at a significantly higher risk, 26 percent do not take any preventative steps to protect their heart health, according to the survey.
Perhaps even more concerning is that the majority (70 percent) of Americans are unaware of all the symptoms of heart disease, even though two out of three (64 percent) have or know someone who has the disease. Only 30 percent of Americans correctly identified unusual fatigue, sleep disturbances and jaw pain as all being signs of heart disease — just a few of the symptoms that can manifest.
“Heart disease is the No. 1 killer of men and women in this country, so it’s disappointing to see that so many Americans are unaware of the severity of not taking action to prevent heart disease, or how exactly to do so,” said Steven Nissen, M.D., Chairman of Cardiovascular Medicine at Cleveland Clinic. “This is a disease that can largely be prevented and managed, but you have to be educated about how to do so and then incorporate prevention into your lifestyle.”
Many Americans believe the myth that fish oil can prevent heart disease.
Vitamins are viewed — mistakenly — as a key to heart disease prevention.
There is a lack of awareness about secret sodium sources.
Americans believe there is a heart disease gene.
There is no single way to prevent heart disease, given that every person is different,” Dr. Nissen added.
“Yet there are five things everyone should learn when it comes to their heart health because they can make an enormous difference and greatly improve your risk:
know your cholesterol,blood pressure, and body mass index numbers,
do not use tobacco,
and know your family history.
Taking these steps can help lead to a healthier heart and a longer, more vibrant life.”
Related articles (variety of views, for informational purposes only)
[AHA article] (Aerobics /Preventive Medicine pioneer) Dr. Kenneth Cooper is keynote speaker at Scientific Sessions 2013
Back in college I took a “physical fitness” class. One of Dr. Cooper’s books was required reading. Very inspiring. Good to see he is still a living example of his well tested theories of aerobic exercise and wellness program benefits.
From the 18 November American Heart Association article
In the early 1960s, when the great Space Race was being fueled by the escalating Cold War, a former track and basketball star from Oklahoma envisioned himself soaring through the Milky Way.
This tall, lanky fellow was an Army doctor, but the lure of space flight led him to transfer to the Air Force. He became certified in aerospace medicine. Then he developed training programs for astronauts – some for before they took off, others to help them remain in shape while floating weightlessly in outer space. All along, his sights were set on becoming among a select group of “science astronauts.”
Imagine how different life on Earth would be today if Kenneth Cooper, MD, MPH, hadn’t shifted gears.
Cooper actually was still in the Air Force when he published “Aerobics,” a book that did as much for the health of Americans as the Apollo 11 lunar landing did for the aerospace industry. Cooper’s book, by the way, came out first – more than a year before Neil Armstrong planted the U.S. flag on the moon.
That book is now available in more than 40 languages. Cooper has spoken in more than 50 countries, and written 18 more books. He is the “Father of Aerobics” and a big reason why the number of runners in the United States spiked from 100,000 when his book came out to 34 million in 1984.
Having proven the benefits of preventive medicine and wellness in the military, he was ready to shift to the private sector.
The private sector, however, wasn’t ready for him.
When he opened his clinic in Dallas, naysayers told him, “You can’t limit your practice to taking care of healthy people. People only want to see their physicians when they’re sick.” And those were the kind ones. Others turned him in to the local medical society’s board of censors.
“They thought I was going to kill people by putting them on treadmills for stress testing,” Cooper said. “I’d been doing it in the Air Force for 10 years!”
The big picture turned out more clearly. Baby Boomers became exercisers, triggering a fitness craze that produced what he calls “the glory years of health in America.” As Boomers have aged, and future generations have made fitness a lower priority, health had spiraled in the wrong direction. It’s been 17 years since the Surgeon General recommended 30 minutes of physical activity most days of the week, and the statistics show that most Americans aren’t doing it.
“For many years, I’ve put people into five health categories, ranking them from very poor to excellent. Research constantly shows that major gains can be made by moving up just one category, even if it’s just from very poor to poor,” Cooper said. “If we can get the 50 million Americans who are totally inactive today to move up just one category, think of the dramatic effect that would have. Just by avoiding inactivity!”
- A Prescription From the ‘Father of Aerobics’ – Exercise Is Medicine (debbiestrauch.wordpress.com)
- Aerobic Exercise Improves Memory, Brain function and Physical Fitness (parasyaseen.wordpress.com)
Some key policy changes that need to be made in the United States in order to prevent illness and improve the health of millions of Americans have just been outlined in the Trust for America’s Health (TFAH) latest Healthier Americareport.***
The report includes a range of suggestions that focus on the prevention of chronic diseases, which currently affect more than half of the U.S. population. This would also help address the health problems facing today’s youth who are set to be the first generation that are less healthy than their parents. …
The recommendations involve some new and innovative approaches:
- Implementing a series of foundational capabilities to improve the country’s health system as well as restructuring public health programs with sustained funding.
- Establishing partnerships with nonprofit hospitals to develop new community benefit programs and expand support for prevention.
- Encourage that insurance providers compensate for all types of prevention strategies
- Ensuring that the Prevention and Public Health Fund continues and improve awareness of the Community Transformation Grant program.
- Maintain workplace wellness programs with employers as well as local and state governments.
The report also includes information about recommendations that are already in action:
- The Accountable Care Community (ACC) brought more than 70 different partners to help patients with type 2 diabetes in and out of the doctor’s office. The ACC managed to reduce the cost of care by more than 10 percent per month for patients with type 2 diabetes – meaning savings of around $3,185 per person yearly.
- The Boston Children’s Hospital implemented The Community Asthma Initiative (CAI) with the purpose of supporting children with asthma in the Boston area. The initiative helped reduce hospital admissions due to asthma-related causes by around 80 percent as well as reducing emergency visits due to asthma by 60 percent.
The report concludes that there are 10 main public health issues that need addressing:
- tobacco use
- healthy aging
- improving the health of minorities
- healthy babies
- environment health threats
- injury prevention
- controlling infectious diseases
- food safety
- Prevention urged to avoid a national health catastrophe (bizbeatblog.dallasnews.com)
- New Report from HSC and Trust for America’s Health Calls for Federal Action to Close Achievement Gap by Addressing School Health (healthyschoolscampaign.typepad.com)
- Comment: Take prevention seriously, make it a priority (timescolonist.com)
- Insight: Think preventive medicine will save money? Think again. (greatriversofhope.wordpress.com)
- The Seven States Least Prepared for Disaster (247wallst.com)
- Hawaii Rises to Second Healthiest State in Nation (damontucker.com)
- “Walk Across Texas” promotes healthier living (victoriaadvocate.com)
- National Shopping Program Aims To Support A Healthier Hispanic Community (paramuspost.com)
- Wendell Potter: Getting Young People to Work Against Their Own Best Interests: Here’s How It’s Done (huffingtonpost.com)
Rational Rationing vs. Irrational Rationing By DAVID KATZ, MD in the 13 September 2012 article at The Health Care Blog
n a system of universal, or nearly universal health insurance such as in Massachusetts, decisions about what benefits to include for whom are decisions about the equitable distribution of a limited resource. If that is rationing, then we need to overcome our fear of the word so we can do it rationally. By design or happenstance, every limited resource is rationed. Design is better.
In the U.S. health care system, some can afford to get any procedure at any hospital, others need to take what they can get. Some doctors provide concierge service, and charge a premium for it. Any “you can have it if you can afford it” system imposes rationing, with socioeconomic status the filter. It is the inevitable, default filter in a capitalist society where you tend to get what you pay for.
That works pretty well for most commodities, but not so well for health care. As noted, failure to spend money you don’t have on early and preventive care may mean later expenditures that are both much larger, and no longer optional — and someone else winds up paying. If you can’t afford a car, you don’t get one; if you can’t afford care for a bullet wound — if you can’t afford CPR — you get it anyway, and worries about who pays the bill come later.
But those costs, and worries, do come later — and somewhere in the system, we pay for them.
By favoring acute care — which can’t be denied — our current system of rationing dries up the resources that might otherwise be used for both clinical preventive services and true health promotion. Fully 80 percent of all chronic disease could be eliminated if our society really rallied around effective strategies for tobacco avoidance, healthful eating, and routine physical activity for all. But when health care spending on the diseases that have already happened is running up the national debt, where are those investments to come from? The answer is, they tend not to come at all. And that’s rationing: not spending on one thing, because you have spent on another.
Nor is this limited to health care. The higher the national expenditure on health-related costs, the fewer dollars there are for other priorities, from defense, to education, to the maintenance of infrastructure. If cutting back on defense calls the patriotism of Congress into question, then classrooms get crowded and kids are left to crumble. Apparently, it is no threat to patriotism to threaten the educational status of America’s future. …
- How Would You Like Your Rationing – Rational, or Irrational? (thehealthcareblog.com)
- U.S. health care system wastes $750B a year (cbc.ca)
- Waste and Promise Seen in U.S. Health Care System (nytimes.com)
More than 16 million people with Medicare get free preventive services in 2012 Affordable Care Act made many preventive services no cost to beneficiaries (with link to a planning guide)
Affordable Care Act made many preventive services no cost to beneficiaries
The Affordable Care Act – the new health care law – helped over 16 million people with original Medicare get at least one preventive service at no cost to them during the first six months of 2012, Health and Human Services (HHS) Secretary Kathleen Sebelius announced today. This includes 1.35 million who have taken advantage of the Annual Wellness Visit provided by the Affordable Care Act. In 2011, 32.5 million people in Medicare received one or more preventive benefits free of charge.
“Millions of Americans are getting cancer screenings, mammograms and other preventive services for free thanks to the health care law,” said Secretary Sebelius. “These new benefits, made possible through the health care law, are helping people stay healthy by giving them the tools they need to prevent health problems before they happen.”
Prior to 2011, people with Medicare faced cost-sharing for many preventive benefits such as cancer screenings. Through the Affordable Care Act, preventive benefits are offered free of charge to beneficiaries, with no deductible or co-pay, so that cost is no longer a barrier for seniors who want to stay healthy and treat problems early.
The law also added an important new service for people with Medicare — an Annual Wellness Visit with the doctor of their choice— at no cost to beneficiaries.
For more information on Medicare-covered preventive services, please visit: http://www.healthcare.gov/law/features/65-older/medicare-preventive-services/index.html
To learn what screenings, vaccinations and other preventive services doctors recommend for you and those you care about, please visit the myhealthfinder tool at www.healthfinder.gov.
- Half on Medicare in AZ use free preventive care (Rim Country Gazette)
- Pennsylvania seniors with Medicare receive free screenings (Times-Tribune)
- Michigan seniors strive to stay healthy (TheDailyReporter)
Ask Medicare Helps Caregivers Plan for the Future (Center for Medicare and Medicaid Services)
Baltimore, MD, June 28, 2012 /PRNewswire/ — Now is an ideal time for caregivers to get organized, manage personal finances and plan for the future. Effective long-term planning can help bring peace of mind and is particularly important for the nation’s growing number of caregivers who must manage their own affairs while attending to the health and well-being of another. Nearly 66 million U.S. residents¹ provide care for a chronically ill, disabled or aging family member or friend. This can involve:
- Setting up doctor appointments for the many free, preventive services available to Medicare beneficiaries,
- Reviewing drug plan coverage,
- Planning for changes in in-home care needs, or
- Preparing for a transition from the home to an assisted living or nursing home facility.
The Centers for Medicare and Medicaid Services initiative, Ask Medicare, can help caregivers plan by offering a wealth of consumer-focused information, including personal stories from other caregivers on overcoming common challenges, a free e-newsletter, and decision-making tools addressing a range of health care issues. The “How Can you Plan for the Future?” checklist provides planning ideas.
Contraceptive use likely prevents more than 272,000 maternal deaths from childbirth each year, according to a new study led by researchers at the Johns Hopkins Bloomberg School of Public Health. Researchers further estimate that satisfying the global unmet need for contraception could reduce maternal deaths an additional 30 percent. Their findings were published July 10 by The Lancet as part of a series of articles on family planning.
“Promotion of contraceptive use is an effective primary prevention strategy for reducing maternal mortality in developing countries. Our findings reinforce the need to accelerate access to contraception in countries with a low prevalence of contraceptive use where gains in maternal mortality prevention could be greatest,” said the study’s lead author, Saifuddin Ahmed, MBBS, PhD, associate professor in the Bloomberg School’s departments of Population, Family and Reproductive Health, and Biostatistics. “Vaccination prevents child mortality; contraception prevents maternal mortality.”
Effective contraception is estimated to avert nearly 230 million unintended births each year. Worldwide, roughly 358,000 women and 3 million newborn babies die each year because of complications related to pregnancy and childbirth. Nearly all of these deaths occur in developing countries, where 10 to 15 percent of pregnancies end in maternal death due to unsafe abortions….
- Melinda Gates responds to contraception program-controversy (with video interview, CNN 6 July 2012)
“Part of what I do with the (Gates) Foundation comes from that incredible social justice I had growing up and belief that all lives, all lives are of equal value,” said Gates during a recent interview with CNN chief medical correspondent Dr. Sanjay Gupta.
About the flak over her Catholicism she said: “We’re not going to agree about everything, but that’s OK.”
Gates is promoting an ambitious family planning program — which includes raising billions of dollars to provide contraceptives to 120 million women worldwide — at the London Summit on Family Planning July 11.”New Study Finds Little Progress in Meeting Demand for Contraception in the Developing World (press release from Guttacher Institute, 19 June 2012)
- Where’s the Controversy in Saving Lives? by Melinda Gates (Health Care Blog, 7 July 2012)
- New Study Finds Little Progress in Meeting Demand for Contraception in the Developing World (Guttmacher Institute press release, 19 June 2012)
A new study by the Guttmacher Institute and UNFPA, the United Nations Population Fund, finds that the number of women in developing countries who want to avoid pregnancy but are not using modern contraception declined only slightly between 2008 and 2012, from 226 to 222 million. However, in the 69 poorest countries—where 73% of all women with unmet need for modern contraceptives reside—the number actually increased, from 153 to 162 million women.The report, Adding It Up: Costs and Benefits of Contraceptive Services—Estimates for 2012, finds that 645 million women of reproductive age (15–49 years) in the developing world are now using modern contraceptive methods, 42 million more than in 2008. ….
Timing Pregnancy an Important Health Concern for Women (Apr. 11, 2012) — A new article highlights the importance of a woman’s ability to time her childbearing. The author asserts that contraception is a means of health promotion and women who work with their health care … > read more
- Contraceptive use averts 272,000 maternal deaths worldwide (esciencenews.com)
- 100,000 Women’s Lives Could Be Saved By Expanded Access To Contraception (thinkprogress.org)
- Contraception Can Prevent More Than 272,000 Maternal Deaths (ibtimes.com)
- Contraceptive use averts 272,000 maternal deaths worldwide (eurekalert.org)
- Fulfilling Contraception Needs Could Lower Maternal Mortality Drastically, Study Says (nytimes.com)
- Contraception saves 250,000 lives each year: study (rawstory.com)
- Better contraception could save 100,000 lives (independent.co.uk)
- Using birth control will cut deaths, study finds (smh.com.au)
- Study Says Meeting Contraception Needs Could Cut Maternal Deaths by a Third (thewip.net)
- Too many mothers still dying (cnn.com)
- Osotimehin maternal deaths (edition.cnn.com)
As we enter 2012, many patients will be changing to new insurance plans.
And for a few, deductibles will be rising.
One thing that’s emphasized in the Affordable Care Act, however, is that preventive services would remain “free.”
However, consider this story of a man, who thought he wouldn’t have to pay for his screening colonoscopy, instead was charged over $1,000 for the procedure.
From USA Today,
Bill Dunphy thought his colonoscopy would be free.
His insurance company told him it would be covered 100 percent, with no copayment from him and no charge against his deductible. The nation’s 1-year-old health law requires most insurance plans to cover all costs for preventive care including colon cancer screening. So Dunphy had the procedure in April.
Then the bill arrived: $1,100.
The reason? During the procedure, polyps were found and rightfully removed. But in doing so, it changed the colonoscopy from a screening procedure to a diagnostic procedure, thus making it applicable to the patient’s deductible.
Such semantics are important, as insurance companies will seize them at every opportunity to pass on costs to both patients and hospitals….
- Preventive care: It’s free, except when it’s not (goerie.com)
- Preventive care: It’s free, except when it’s not (usatoday.com)
- Loophole in U.S. law means not all preventive care free (ctv.ca)
- Preventive care: It’s free, except when it’s not (sfgate.com)
- Preventive care: It’s free, except when it’s not (seattlepi.com)
- Preventive Care Is Free — Except For When It’s Not (huffingtonpost.com)
- Preventive Care: It’s Free, Except When It’s Not (maboulette.wordpress.com)
- Preventive care: It’s free, except when it’s not (mysanantonio.com)
- Preventive care: It’s free, except when it’s not (seattletimes.nwsource.com)
- Know What to Expect From Colonoscopy Prep (everydayhealth.com)
Excerpt from Dr. Rubin’s blog
In 1979, the publication of Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention represented the first report emphasizing the importance of decreasing early mortality through health promotion and disease prevention programs. This led to the Centers for Disease Control and Prevention’s development of specific, national 10-year health objectives, contained within a collaborative initiative known as Healthy People. The 2010 objectives fell within 28 public health focus areas including cancer, diabetes, immunizations and infectious diseases, injury and violence prevention, nutrition and overweight, and many others (the full list can be found here).
So as a country, how well did we meet the Healthy People 2010 objectives? I guess that depends on your definition of success. A final review of the 2010 results showed that of the 733 objectives for which data were available:
23% met the 2010 targets
48% made progress toward the 2010 targets
5% showed no change from baseline
24% moved away from the 2010 targets
Structured Evidence Queries (SEQs) for the Healthy People 2020 Leading Health Indicators
Healthy People 2020 (HP2020) is a ten-year health promotion program for improving the health of all Americans. Led by the U.S. Department of Health and Human Services, HP2020 is organized into 42 subject areas with 600 public health objectives. These objectives, developed and selected through consultation with a broad range of organizations, groups, and individuals, provide a framework for monitoring and measuring improvements in health status of the American population over the ten-year period from 2010 to 2020.
The Leading Health Indicators (LHI) are a set of objectives carefully selected to represent high-priority health issues and actions that can be taken to address them.
The Healthy People 2020 Structured Evidence Queries (SEQs) are pre-formulated PubMed search strategies intended to support both public health practitioners and researchers in their efforts to achieve specific HP2020 public health objectives. The HP2020 SEQs provide citations to the most up-to-date peer-reviewed literature from the PubMed database of the National Library of Medicine.
For persons interested in using the SEQs or other NLM resources to create products for the LHI App Challenge, e.g., for mobile devices, please contact the PHPartners Team. More general information about PubMed linking and E-utilities is available from Entrez Programming Utilities Help
The Structured Evidence Queries link each Leading Health Indicator objective to PubMed citations related to that objective. For two LHI objectives, in Clinical Preventive Services (vaccination rate for toddlers) and Injury and Violence (fatal injuries), a set of SEQs is provided to further assist users. Your feedback will help us refine the SEQs over time.
To use an HP2020 SEQ to search PubMed, please expand the Leading Health Indicator topic area (“+”) and click the button by the LHI objective.
[Go to http://phpartners.org/hp2020_lhi.html to use the structured evidence queries below]
1. Access to Health Services
2. Clinical Preventive Services
3. Environmental Quality
4. Injury and Violence
5. Maternal, Infant and Child Health
6. Mental Health
7. Nutrition, Physical Activity and Obesity
8. Oral Health
9. Reproductive and Sexual Health
10. Social Determinants
11. Substance Abuse
- Healthy People? Not Quite Yet. (drrubinblog.com)
- Improving health will take a village (jflahiff.wordpress.com)
- Collaboration Of Public And Private Health Partners Is Essential For Health Improvement (medicalnewstoday.com)
- Syphilis Rises 36% In USA In Four Years (jflahiff.wordpress.com)
- Thank you Public Health! (healthygenerations.wordpress.com)
- Public Health Investments Pay Off (jflahiff.wordpress.com)
- Public health experts condemn plans (mirror.co.uk)
Excerpt from Is preventive health really preventative?
I am not necessarily disputing any evidence or recommendations that have been introduced, but the false sense that we have the ability to “prevent” an illness or disease from happening in the first place. This can lead to unrealistic expectations and negative backlash. Yes, we may be able to detect an early cancer prior to it’s spread or immunize individuals against certain infectious diseases. But prevent altogether? Sadly, I don’t think so – in fact, I know so.
That is why I am using the term pro-active health rather than prevention. There are actions that individuals can take to lower their risks from disease and illness and I believe that is taking a pro-active part in one’s health. We do this in the hopes of longevity, wellness, disease avoidance and early detection (if illness is identified).
- Study finds shifting disease burden following universal Hib vaccination (eurekalert.org)
- Maintaining a Flu-free Family (education.com)
- Arctic Lab Expansion Provides Early Detection of Infectious Disease and Bioterrorism (indiancountrytodaymedianetwork.com)
- NBA players not immune to serious illness from norovirus (eurekalert.org)
- Vaccine Could Prevent Mononucleosis And Cancers Linked To Epstein-Barr Virus (medicalnewstoday.com)
- Tuberculosis detector would ferret out disease by scent (theglobeandmail.com)
As a centerpiece of the Patient Protection and Affordable Care Act (ACA) of 2010, the focus on preventive services is a profound shift from a reactive system that primarily responds to acute problems and urgent needs to one that helps foster optimal health and well-being. The ACA addresses preventive services for both men and women of all ages, and women in particular stand to benefit from additional preventive health services. The inclusion of evidence-based screenings, counseling and procedures that address women’s greater need for services over the course of a lifetime may have a profound impact for individuals and the nation as a whole.
Given the magnitude of change, the U.S. Department of Health and Human Services charged the IOM with reviewing what preventive services are important to women’s health and well-being and then recommending which of these should be considered in the development of comprehensive guidelines. The IOM defined preventive health services as measures—including medications, procedures, devices, tests, education and counseling—shown to improve well-being, and/or decrease the likelihood or delay the onset of a targeted disease or condition.
The IOM recommends that women’s preventive services include:
- improved screening for cervical cancer, counseling for sexually transmitted infections, and counseling and screening for HIV;
- a fuller range of contraceptive education, counseling, methods, and services so that women can better avoid unwanted pregnancies and space their pregnancies to promote optimal birth outcomes;
- services for pregnant women including screening for gestational diabetes and lactation counseling and equipment to help women who choose to breastfeed do so successfully;
- at least one well-woman preventive care visit annually for women to receive comprehensive services; and
- screening and counseling for all women and adolescent girls for interpersonal and domestic violence in a culturally sensitive and supportive manner.