A Closer Look at Women's Health Centers: Historical Lessons and Future Aims

Introduction

Women's health is a comprehensive care model to prevent, screen, diagnose, and treat conditions in women, while recognizing and appreciating gender differences. It takes a multidisciplinary approach, including but not limited to reproductive care, to approach all stages of a woman's life. ^1,2 Women's health care has made tremendous strides in the last few decades through advancements in reproductive rights, access to and modalities of care, education, training, and research. However, there are still sex and gender differences in health care, often resulting in worse health outcomes for women. A multidisciplinary perspective considering sex and gender is necessary to improve future patient outcomes. ^{3 –5}

In the 1980s, the number of Women's Health Centers (WHC) increased to better serve women in single, comprehensive centers. ^6,7 As a result, there has been a movement toward providing women's health care in such inclusive, multidisciplinary centers. At the turn of the 21st century, numerous studies were done to evaluate the quality of women's health care at WHC, as well as review women's health residency and fellowship training opportunities. Since then, there has been limited research assessing WHC. The coronavirus disease 2019 (COVID-19) pandemic and subsequent reduction in access to ambulatory care have resulted in gaps in women's health care, highlighting health inequities and the disproportionate burden placed on women.

This article aims to review the history of WHC, literature evaluating quality of care at WHC compared with traditional care models, and women's health training opportunities. In the context of the COVID-19 pandemic, we emphasize the potential role for WHC to meet the increased demands in women's health care. In this article, we highlight the capacity of WHC to increase women's access to care, patient/provider satisfaction, and research and educational opportunities.

History of WHC

The second Women's Health Movement (WHM) was initiated in the late 1960s. It focused on increasing reproductive rights, improving birthing practices, including women in health research, and, ultimately, led to the development of WHC as a model of care. ^6,8 Before the WHM, women's primary care was mostly integrated with men's care through internal medicine (IM) or family medicine. Reproductive care was largely conducted through obstetrics/gynecology (ob/gyn) clinics. Any centers dedicated to women were composed of the remaining women's hospitals, which were quickly decreasing in number during that time. ^6,9

After the second WHM, the term “Women's Health Center” was coined. From a survey of 10 WHC in Chicago, the 3 main classifications of WHC included specialty WHC (such as breast or heart centers), reproductive care WHC, and multidisciplinary WHC (primary care, ob/gyn, and educational and psychiatric services). ^10,11 The definition by the American Hospital Association is stated as “an area set aside for coordinated educational and treatment services specifically for and promoted to women as provided by this special unit. Services may or may not include obstetrics but include a range of services other than obstetrics.” ^6,12 For the purposes of this article, the main focus is on multidisciplinary and primary care WHC with some discussion of reproductive care and specialty WHC.

When WHC began developing as a model for care, they often included primary, gynecologic, and obstetric care, with other specialists in a single center. However, they mostly consisted of gynecologic care with limited primary care services due to competition with established primary care providers (PCPs). ⁸ In the early 1980s, more hospitals started adding WHC to their organizations, as well as marketing WHC to women. ^6,7 At the same time, the Veterans Association (VA) surveyed female veterans and found that they lacked access to equal benefits compared with their male counterparts. Female veterans had suboptimal medical and reproductive care with inadequate examinations and had higher rates of cancer, particularly gynecologic cancers. ¹³ Following the publication of these results, the Advisory Committee on Women Veterans was created and established the Center for Women Veterans, pioneering their own WHC. This innovation further motivated development of both public and private WHC. ¹³

In 1994, with an evident increase in WHC throughout the country, the Commonwealth Fund financed the inaugural National Survey of Women's Health Centers. From this survey, it was predicted that there were a total of around 3600 WHC in the United Sates serving 14.5 million women as of 1993. ⁶ Of these WHC, 71% were focused on reproductive care (ob/gyn, public, or Planned Parenthood centers), 12% on primary care (including VA and college centers), and the remaining were specialty centers. Reproductive care WHC were found to have existed the longest, most created before the 1980s.

Post-1980s, the majority of WHC were found to be hospital-sponsored and not-for-profit. Reproductive and primary care WHC, including VA centers, were more likely to be publicly funded than other WHC, but the majority were still associated with hospitals. Primary care WHC were more likely to have a woman medical director (64% vs. 35%–50%) with a higher percentage of women physicians overall (57% vs. 17%–33%) compared with reproductive care and specialty WHC centers. Primary care WHC were also more likely to counsel on menopause (78%), treat menstrual pathologies (91%), and provide hormone therapy (HT; 68%) than other WHC.

Reproductive care WHC were more likely to counsel on contraception, abortion, and infertility, and perform gynecologic examinations compared with other WHC. Reproductive care WHC were less likely to provide general physical examinations and preventative services compared with primary care WHC. Primary care WHC were the most likely to implement a “one-stop shopping” model and serve as patients' “usual source of care” in comparison with all other WHC. Compassionate care, patient empowerment, and shared decision-making were promoted at all WHC. The National Survey of Women's Health Centers was the first to evaluate WHC and provide guidance for the development of future WHC. ⁶

Following the publication of this survey's results in 1996 and 1997, the U.S. Department of Health and Human Services Office on Women's Health designated 12 academic health centers as National Centers of Excellence (CoE) in Women's Health expanding to 15 by 2000. ¹⁴ The purpose of the CoE was to offer women's health services in a single model often with the “one-stop shopping” (single center) framework or the “center without walls” (network of services near CoE) model. ¹⁵ The principal goal of CoE was focused on integrating reproductive and primary care, as well as prioritizing research, education, community outreach, and faculty development. Their stated goal was “to establish and evaluate a new model health care system that unites women's health research, medical training, clinical care, public health education, community outreach, and the promotion of women in health professions around a common mission—to improve the health status of diverse women across the life span.” ¹⁶

Weisman and Squires compared the CoE with 56 other hospital-sponsored and primary care WHC. ¹⁴ They found that the CoE were more likely to be comprising multiple sites connected to a “one-stop shopping” location in comparison with the control WHC. CoE had a higher percentage of PCPs (internists or obstetricians/gynecologists), greater opportunities for physician education and women's health research, and served more nonwhite and Medicare patients. They were equally as multidisciplinary as the control WHC. Weisman and Squires concluded that the CoE placed a greater significance on education, research, and training, while serving a more diverse population than the control WHC. ¹⁴

A focus group study, involving 6 of the CoE with 137 women in 1998, reinforced the idea that many women preferred one center that could provide “comprehensive and coordinated care” focusing on more than reproductive care. Women expressed that seeing multiple providers may be helpful for subspecialty knowledge, but became practically inconvenient with inconsistent relationships when women had to go to multiple sites for different appointments. ¹⁷ These studies highlighted the growing emphasis on academic WHC integrating women's health services with education and research, while also meeting the needs of their female patients. ^14,17

CoE also improved the care of minority and underserved women. Jackson et al. detailed the history of barriers to care for minority women, as well as how CoE addressed these disparities. ¹⁸ Not only were CoE found to serve more diverse populations than other WHC, but they were able to reduce barriers to care by providing interpreting services, implementing an expansive referral program, and leading community outreach initiatives for underserved patients as well. ^14,18 Furthermore, they increased cultural sensitivity training to improve provider knowledge of the patients they were serving. ¹⁸

CoE also placed significant value on diversifying providers to best serve their population; in 1998, six CoE were specifically tasked to increase faculty careers for minority women. Wong et al. qualitatively surveyed these six centers and conducted postsurvey telephone interviews. They found that within the six centers, this was the first time there was a specific focus on minority women faculty, which improved mentorship and recognition of these women. ¹⁹ Improving care of minority women is crucial to reduce existing health disparities, and it is vital to continue to investigate avenues, such as CoE, to reduce these disparities. ⁴

The principles behind CoE—integration, collaboration, and education—are ones that most WHC strived for, but there were obstacles in realizing these aims. Gwinner et al. illustrated some of these challenges, specifically describing resistance to multidisciplinary collaboration at CoE. ²⁰ Patients were used to multiple physicians in different centers and had trouble adjusting to single-center care. Gwinner et al. found that some of these barriers were addressed by formulating interdisciplinary care teams that assisted with patient navigation. ²⁰ They also noted several advantages of CoE, such as greater provider/patient communication, improved access to patient education resources, and increased empowerment of patients. ²⁰ Overall, the CoE brought a new standard of care to WHC and were the first guiding body for non-VA WHC.

Evaluating WHC

After the development and growth of WHC, several studies evaluated WHC compared with traditional primary care and ob/gyn clinics. In 2003, the VA conducted a cross-sectional study by mailing surveys to compare patient satisfaction in the VA WHC versus traditional VA primary care clinics. ²¹ Nine hundred seventy-one women responded across three states and multiple WHC locations. Compared with traditional VA primary care clinics, VA WHC were more likely to serve younger and nonwhite women. At the VA WHC, women were more likely to report excellent overall satisfaction, as well as more privacy, comfort, and dignity preservation. They reported a significantly greater satisfaction in the quality of provider communication, including provider time spent with patients and discussions surrounding sensitive topics, such as sexual and mental health. There was a significantly higher sense of perceived provider knowledge of women's health and disease prevention, as well as increased scheduling and flexibility with female providers at WHC. There were no differences in ability to establish care or receive follow-up care.

This study revealed that overall, women had a better experience in the VA WHC than the traditional VA primary care clinics. ²¹ While this study highlighted patient care issues that mattered to women, the VA model is difficult to generalize to other clinical settings. Specifically, compared with female non-Veterans, female Veterans were older and more likely to be nonwhite, non-Hispanic, single, have insurance, and have a higher income. ²²

Two studies were performed on non-VA-associated WHC, comparing primary and preventative care between WHC and general IM clinics. Harpole et al. performed a cross-sectional study at three university hospitals in Boston by mailing surveys to patients at the affiliated WHC. ²³ From 1942 patients, they found that patients at WHC were younger, more likely to be educated, employed, and single, and had a higher level of physical functioning, but worse mental health. Overall, patient satisfaction was similar in both clinical settings (adjusted odds ratio [OR]: 1.10, 95% confidence interval, CI [0.87–1.387]), but patients were significantly more satisfied with patient/provider interactions at the WHC, for example, doctors understanding concerns (adjusted OR: 1.28, 95% CI [1.03–1.60]). Patients at WHC were more likely to be counseled on HT and dietary calcium than in the general IM clinics, but they were equally likely to have preventative care in both practices. However, patients were more likely to have gender-specific screening, such as breast examinations and Pap smears, by their provider at the WHC than by their ob/gyn. ²³

Phelan et al. also performed a cross-sectional study by mailing surveys to patients at university-affiliated WHC. ²⁴ A total of 706 women responded and patients in the WHC were more likely to be younger and healthier than patients in the general IM clinic, who were older, had more health conditions, and required more visits to their provider. The WHC patients were more likely to have mammograms (adjusted OR: 4.0, 95% CI [1.1–15.2]) and cholesterol monitoring (adjusted OR: 1.6, 95% CI [1.0–2.6]), while less likely to have colon cancer screening with flexible sigmoidoscopy (adjusted OR: 0.5, 95% CI [0.3–0.9]). There were higher rates of HT discussions and breast and cervical examinations at WHC, but this was not statistically significant. The rates of satisfaction, shared decision-making, and expectations were high at both centers, but at the WHC, more patients who wanted a female provider were able to have one. ²⁴

The two cross-sectional surveys performed in these academic settings shed light on questions regarding the patient population and care provided in WHC. ^{23 –25} A consistent finding in these studies was that WHC seem to serve a younger and healthier patient population. ^23,24 This may be due to hospital marketing, the attraction of “one-stop-shopping,” and younger patients proactively choosing physicians at the new WHC rather than continuing care at the traditional clinics. In both studies, there was no difference in overall satisfaction and general preventative screenings at WHC compared with the general IM clinics. ^23,24 At WHC, there were higher reported rates of gender-specific screening and counseling for women's health issues, and patients also reported greater satisfaction with provider interactions.

The previously discussed studies were conducted in the 1990s and early 2000s, and there have been minimal studies published evaluating the current state of WHC since that time. Two surveys more recently evaluated women's health care and women's preferences. In 2015, Hall et al. utilized data from the 2013 National Women's Health Care Experiences and Preferences Study, which randomly sampled women aged 18–55, to evaluate women's provider preferences. ²⁶ From their survey of 981 women, they found that women's health specialists (ob/gyn or women's health generalists) were the most utilized and most preferred sources for reproductive care. They found that older, nonwhite, underinsured, and lower income patients used PCPs (such as generalists, public health clinics, or emergency departments) for reproductive care rather than women's health specialists; although some from this cohort would have preferred women's health specialists. A large majority of patients, typically younger, reproductive-aged women, also utilized their reproductive care provider as their PCP for general care.

They concluded that their findings highlight the need to continue supporting and defining the role of women's health specialists, since a single provider for both general and reproductive care is the preferred model for women. Furthermore, they concluded that their findings may support comprehensive care models that integrate primary and reproductive care to provide increased access to care for vulnerable patients. ²⁶

In 2017, the Kaiser Women's Health Survey conducted telephone interviews of 2751 women between the ages of 18–64. They found that 46% of women have more than one provider, not including dentists or mental health specialists, with the most common source of regular care coming from a provider trained in internal or family medicine. The most common secondary type of care was an ob/gyn, and 58% of women reported seeing an ob/gyn in the past year, with a higher percentage of those patients having private insurance. ²⁷

From these and other similar studies, it seems that generalists tend to see older patients and ob/gyn tend to see younger patients, likely representing varying needs across the life span. ^{23 –28} Women overall preferred reproductive and general care with one provider, especially lower income patients, but close to half of women still receive regular care from multiple providers at different sites. ^{26 –28} Care between traditional care models and WHC is of similar quality with regard to preventative screening and overall satisfaction, but WHC may provide gender-specific screening in one place with increased patient/provider satisfaction. More studies looking at multicenter WHC need to be conducted to better quantify patients' needs and quality of care.

Women's Health Education, Research, and Training

When providers are specifically trained in women's health, they are more likely to become clinical leaders, educators, and researchers. ²⁹ IM physicians should obtain women's health training through core curriculum in their residency programs. They can sometimes augment this training through specified Women's Health Tracks, although these are limited in number, with only eight identified as per the Directory of Residency and Fellowship Programs in Women's Health from 2015. ³⁰ Ob/gyns have training in gynecologic and obstetric women's health with limited primary care training.

Although the American Board of Internal Medicine and the Accreditation Council for Graduate Medical Education (ACGME) have published core competencies and educational requirements for IM women's health topics, there is still a lack of training. ^31,32 IM residents have significant gaps in ambulatory care knowledge and have reported low comfort levels in many women's health topics. ^33,34 Program directors also reported not including important women's health topics in curricula with limited training opportunities, although valuing this education for their trainees. ³⁵ There have been advances to close this gap, such as integrating interdisciplinary curriculums and adding WHC to ambulatory experiences. ^36,37 However, it is unclear if this educational gap has been effectively addressed given the lack of publication or limited evaluation of programs' curricula. Curricula have been found to increase behaviors and knowledge toward women's health, but further research is needed. ³⁸

Women's Health Fellowships (WHF) may be an avenue to increase education, training, and research in women's health. The creation of the WHF in 1990 served to specifically increase research advances in women's health. As Carnes et al. described, women's health and women in academia are closely connected. Greater opportunities for women's health education and research could result in more women's health leaders who would then invest back into the system, ultimately improving attention to women's health training and care. ³⁹ Currently, WHF are not accredited by the ACGME. Foreman et al. revealed the lack of women's health exposure in early medical education and argued for the accreditation to improve women's health education by creating specialists in the field to increase recruitment and mentorship for future women's health specialists. ⁴⁰ However, Carnes and Vogelman responded by showing that accrediting the WHF would not improve overall care, and time should be spent increasing women's health training in IM and ob/gyn residencies. ⁴¹

Following this, Tilstra et al. reviewed the VA WHF program and found that graduates excelled in administration, research, and education in women's health. This success was strongly linked to early mentorship and obtainment of additional advanced degrees through the WHF program. After fellowship, these physicians were often leaders in their institutions, researched the disparity of women's health training, advocated nationally for women's health, and created tracks and programs for trainees. ²⁹

Whether resolved through increased training during residency or through dedicated fellowships, it is evident that there is a gap in women's health training. ^{33 –35} It is imperative that trainees are competent in core women's health topics. ⁴² Developing women's health leaders who contribute to the field may help meet these demands, and it is imperative to obtain support from academic leaders who understand the importance of integrated women's health care. ¹⁵ Educating trainees and decreasing the knowledge gap has benefits for patients and providers, such as improved women's health care and career advancement. ^{29,38 –41} Studies evaluating the best way forward for women's health training in both IM and ob/gyn are necessary.

COVID-19 Pandemic and Women's Health Care Implications

The COVID-19 pandemic has presented substantial challenges for the health care system. Patients have been significantly impacted with limited access to primary and specialty ambulatory care. In April 2020, it was reported that there was about a 50%–60% decrease in ambulatory office visits, with primary care and ob/gyn offices reporting about a 50% decrease in visits. ^43,44 Compared with April 2019, mammograms and Pap smears were down by 75%–90%, colonoscopies by 80%–90%, blood pressure evaluations by 50%, and cholesterol testing by 40%. ^{45 –47} Although telehealth provided a good option for some care, assessment of these measures occurred less frequently during telehealth visits leading to suboptimal care. ⁴⁴

In addition to preventative screenings, gender-based services for women were significantly affected. One-third of women in the United States reported that they had postponement or cancelations in sexual and reproductive care with a greater proportion for women who were nonwhite and had a lower socioeconomic status. ^48,49 Importantly, women have reported an increased desire to avoid pregnancy as a result of the COVID-19 pandemic. ^48,50 However, due to food, housing, and transportation insecurity in combination with decreased access to reproductive services, it is predicted that there is an increased chance of unintended pregnancies in the United States particularly in low-income and minority populations. ⁵¹

Worldwide, the United Nations Population Fund predicts that there will be seven million unintended pregnancies as a result of the pandemic with an estimated 1.4 million unintended pregnancies already occurring. ⁵⁰ From the Ebola and Zika outbreaks, we learned that interpartner and gender-based violence increased during public health crisis times. It is predicted that for every 3 months in shelter-in-place orders, there are 15 million occurrences of gender-based violence, which has an increased association with morbidity and mortality for women. ⁴⁹ Furthermore, women make up 76% of U.S. health care workers and have increased caregiver responsibilities, leading to increased mental and physical stress and decreased time for personal health care. ⁴⁹

In October 2020, primary care in-office visits returned to prepandemic baselines, mostly for larger practices and Medicare patients. ⁵² Overall, all patients will have a reduction in cancer and chronic disease screening and women face increased health risks associated with the pandemic. In the current pandemic state, WHC and other multispecialty, single-site care centers may offer greater safety and convenience to patients by providing ambulatory health care services at one location. This could decrease exposures for patients and health care providers, while likely maintaining quality preventative care, considering the studies reviewed here.

For women, combining primary and reproductive care in one center could allow general medical and reproductive care services to be provided simultaneously. Social work and mental health services in one location, as many WHC have, could also support the increased stress and violence women face during pandemics. WHC or other multispecialty centers and their impact on care have not been well studied during pandemics, including the current COVID-19 pandemic. More studies on the pandemic's effects on primary care, as well as studies focused on WHC, are important to determine future steps to best serve patients effectively and safely.

Conclusions and Clinical Implications

There have been great strides in improving the quality and accessibility of women's health care, but there is still more work to be done. The growth of WHC aimed to provide women with comprehensive care in one center, as well as increase opportunities for education and research. Overall, WHC have been successful in achieving high satisfaction rates, particularly with provider/patient relationships and high rates of preventative and gender-specific screening.

In all studies, there were significance differences between the patients served by WHC versus traditional clinics. The WHC served a younger, more diverse, and healthier population, often with a lower socioeconomic status. Notably, patients of lower economic status did report preferring providers in one location. WHC may benefit these patients by allowing more convenience, less time to coordinate care, and lower cost of care, although studies are needed to evaluate these potential benefits.

In addition, CoE have specifically sought to advance support of diverse patients and providers, as well as increase education and research opportunities. Representation and empowerment of minority women faculty members should be a priority and making this an aim of all WHC, as CoE have done, could help in reaching this goal. WHC may be an optimal setting to continue to address racial, gender, and socioeconomic health disparities. During the current COVID-19 pandemic, reduced access to primary and reproductive care for women will likely have significant impacts on their health outcomes. WHC may provide better access to care in a single center for patients and mitigate some of the disparities in preventative and treatment services.

There are many unanswered questions about WHC. Primarily, there has been minimal research conducted in the past two decades and the current state of WHC should be described, including the number, location, and disciplines represented within centers. General preventative, gender-specific, and gynecologic care should be reevaluated in WHC compared with traditional primary care and ob/gyn clinics. It should be determined whether WHC provide cost efficiency and convenience benefits for patients, especially patients of lower socioeconomic status. WHC should also be evaluated in terms of education and research advances, as these were goals of the CoE. In addition, the clinical impact of WHC during the COVID-19 pandemic should be quantified. Most importantly, studies should evaluate whether WHC improve health outcomes.

Finally, improvements in medical education for trainees are crucial to providing quality women's health care across all medical domains. WHC have significant potential to improve patient care and provider opportunities and better address sex and gender determinants of health; further evaluation of WHC would allow us to learn how to better serve our female patients.