Preconception Health and Disability Status Among Women of Reproductive Age Participating in the National Health and Nutrition Examination Surveys,2013

Abstract

Background:

Preconception health is a critical determinant of health outcomes for women and their offspring. Given higher rates of prenatal and postpartum complications among women with disabilities, it is important to investigate a range of preconception health indicators in this population.

Materials and Methods:

Data were from women of reproductive age (18–44 years) who participated in the National Health and Nutrition Examination Surveys, 2013–2018. Disability was self-reported as serious difficulty hearing, seeing, concentrating, walking, dressing, and/or running errands due to physical, mental, or emotional conditions. Preconception health indicators were adapted from those developed by the Core State Preconception Health Indicators Working Group. Multivariable Poisson regression estimated adjusted prevalence ratios (aPRs) and 95% confidence intervals of preconception health indicators among women with disabilities compared with those without disabilities.

Results:

Of 4055 women, 601 (15%, weighted) reported having any disabilities, and of these women, 220 (6%) reported having 2 or more types of disabilities. Women with any disabilities were more likely to have suboptimal preconception health indicators compared with women without disabilities, including low education and household income, no recent dental visit, difficulty getting pregnant, current smoking, binge drinking, drug use, obesity, no multivitamin use, physical inactivity, long sleep durations, asthma, hypertension, and sexually transmitted infections (aPRs from 1.1 to 2.0). The greatest disparities between women with and without disabilities were for indicators of self-rated poor or fair general health, depression, and diabetes, with aPRs ranging from 2.4 to 3.8.

Conclusions:

Disparities in preconception health indicators are modifiable and may be addressed through adequate access to health care, interventions targeting lifestyle and health behaviors, and education and training for all health practitioners.

Introduction

A woman's health status before conception is an important determinant of pregnancy complications and birth outcomes as well as chronic health conditions for herself and her offspring.^1
–3 Supporting women to achieve optimal preconception health is recognized as a primary prevention strategy. The United States (U.S.) Centers for Disease Control and Prevention (CDC) and other national- and state-level organizations have systematically defined and prioritized preconception health indicators for women and incorporated them into surveillance strategies, clinical practice guidelines, and evidence-based interventions and policies.^4,5

In 2007, the Core State Preconception Health Indicators Working Group (convened by the CDC and composed of experts from 7 states) developed a list of 45 optimal preconception health indicators within 10 health domains, including social determinants of health, chronic medical conditions, lifestyle behaviors, and access to and utilization of health care services.⁴ The majority of these indicators are modifiable. Given the long-term and potential transgenerational influences of preconception health,^2,3 it is necessary not only to evaluate preconception health indicators among all women of reproductive age (18–44 years) but also to identify women who are at high risk for disparities in these indicators.

In the U.S. ∼18% of women of reproductive age report at least one disability related to hearing, vision, cognition, mobility, self-care, or independent living.⁶ Previous studies using data from the Rhode Island and Massachusetts Pregnancy Risk Assessment Monitoring System (PRAMS), a state-level surveillance system of U.S. women with recent births, found that women with disabilities were more likely to report health-related risk factors around the time of pregnancy compared with those with no disabilities, including prepregnancy obesity and other chronic conditions,⁷ depression,⁸ and smoking.^7,9

Other studies among women of reproductive age who participated in the U.S. Behavioral Risk Factor Surveillance System (BRFSS),^10
–12 a telephone survey of health risk behaviors among adults aged 18 years and older, and those within the Ontario (Canada) health system¹³ also found greater prevalence of preconception health risks associated with disability status. Inadequate health care use (e.g., dental visits), poor general and mental health, obesity, diabetes, asthma, and limited social support were consistently observed for women with disabilities compared with those without disabilities.

Collectively, these findings are concerning. Women with disabilities become pregnant at rates comparable to those of all women of reproductive age,^14,15 and they are more likely to experience pregnancy complications and poor birth outcomes compared with women without disabilities, which may at least partially be attributed to disparities in preconception and prenatal health indicators.^16
–18

There are few resources available to investigate the health of women of reproductive age with disabilities. Previous studies using PRAMS^7
–9 and BRFSS (before 2017)^11,12 were limited in their assessment of women's disability status with only one and two questions, respectively, addressing limitations in any activities because of physical, mental, or emotional problems and any health problems requiring the use of special equipment. The U.S. National Health and Nutrition Examination Survey (NHANES) is a nationally representative program of studies that collects a range of sociodemographic, behavioral, and clinical data from individuals of all ages.¹⁹ Beginning in 2013, NHANES incorporated six questions about disability status.

These questions specifically address serious difficulties related to hearing, seeing, concentrating, walking, dressing, and/or running errands due to physical, mental, or emotional conditions. In the current analysis, we leveraged these data to examine associations between self-reported disability status and preconception health indicators among U.S. women of reproductive age. We also considered several indicators that were not examined in prior studies, including sleep, fruit and vegetable intakes, family planning, and drug use. Our findings may contribute to the design and implementation of clinical and public health strategies that aim to reduce reproductive health disparities faced by women with disabilities.

Materials and Methods

NHANES is conducted by the National Center for Health Statistics (NCHS) and annually collects interview, physical examination, and laboratory data from a nationally representative sample of ∼5000 individuals of all ages.¹⁹ The purpose of NHANES is to assess the health and nutrition status of the U.S. population. For the current analysis, we restricted our sample to include data from all women aged 18–44 years who participated in NHANES 2013–2018 because these three survey cycles (2013–2014; 2015–2016; and 2017–2018) included a disability questionnaire with specific questions on disability status. We excluded women who had a previous hysterectomy (n = 120). Informed consent was obtained from all participants, and approval for the studies was obtained from the NCHS Research Ethics Review Board. Descriptions of NHANES and all procedures are detailed online (https://www.cdc.gov/nchs/nhanes/index.htm). The current study was exempt from human subjects review by the New York University Institutional Review Board.

Disability status

Self-reported disability status was based on responses (yes or no) to six questions: (1) “deaf or serious difficulty hearing”; (2) “blind or serious difficulty seeing even when wearing glasses”; (3) “serious difficulty concentrating, remembering, or making decisions”; (4) “serious difficulty walking or climbing stairs”; (5) “difficulty dressing or bathing”; and (6) “difficulty doing errands alone such as visiting a doctor's office or shopping.” We dichotomized self-reported disability status as none or any disabilities. We further categorized any self-reported disabilities as four disability types: sensory (1 and 2); cognitive (3); movement (4); and self-care (5 and 6).²⁰ For analyses, we examined associations for women who reported only one type of self-reported disability and for those who reported two or more types of disabilities, compared with women with no disabilities.

Preconception health indicators

We adapted the 2007 Core State Preconception Health Indicators Working Group's list of 45 preconception health indicators within 10 preconception health domains based on data available in NHANES (Table 1).⁴ NHANES collected information related to 22 preconception health indicators across 9 domains. Information was not available for the social support domain (e.g., physical and mental abuse) or indicators specific to pregnancy (e.g., “ever told by healthcare provider that you had diabetes prior to pregnancy”) or the postpartum (e.g., “postpartum depression”). When applicable, we used other information collected by NHANES to serve as surrogate preconception health indicators. For the current analyses, we defined and examined the following preconception health domains and corresponding indicators:

Table 1.

Core State Preconception Health Domains and Indicators and Corresponding Variables Collected Among Women of Reproductive Age (18–44 years) Participating in the National Health and Nutrition Examination Surveys, 2013–2018

PCH domain	PCH indicator	NHANES variable
General health status and life satisfaction	Percentage of women with report of good, very good, or excellent health	Self-rated general health
Social determinants of health	Percentage of women with high school education or greater	Level of education
Social determinants of health	Percentage of women living at or below 200% of the Federal Poverty Threshold	Household income based on Federal Poverty Threshold
Health care	Percentage of women with some type of health care coverage (current)	Current health care coverage
	Percentage of women with a live birth who have some type of health care coverage (1 month before pregnancy)	—
	Percentage of women who had routine checkup in past year	How long since last health care visit
	Percentage of women with a live birth who had postpartum checkup	—
	Percentage of women with a live birth who had teeth cleaned during year before pregnancy	How long since last dental visit
	Percentage of women with Pap test within past 3 years	—
	Percentage of women with a live birth who received of preconception counseling about healthy behaviors and prevention strategies	—
Reproductive health and family planning	Percentage of women with a live birth who had previous preterm birth	—
	Percentage of women with a live birth who had previous live birth more than 3 weeks before the due date	—
	Percentage of women with a live birth who had previous miscarriage, fetal death, or stillbirth in 12 months before most recent live birth	—
	Percentage of women with a live birth who had interpregnancy interval less than 18 months (between previous and most recent live birth)	—
	Percentage of women with a live birth who had unintended or unwanted pregnancy	—
	Percentage of women with a live birth who were not trying to get pregnant and not using any form of contraception with partner	—
	Percentage of women with a live birth who were not trying to get pregnant and using some form of contraception with partner	Ever taken birth control
	Percentage of women with a live birth who uses fertility drugs or medical procedures for pregnancy	Had regular periods during past year
		Saw physician because unable to become pregnant
		Tried for a year to become pregnant
Tobacco, alcohol, and substance use	Percentage of women who currently smoke	Current smoker
	Percentage of women who participated in heavy drinking at least once during previous month	Frequency of alcohol consumption during previous year
	Percentage of women who participated in binge drinking at least once during previous month	Number of times had four or more drinks in 2 hours
	Percentage of women with a live birth who drank any alcohol during 3 months before pregnancy	—
	Percentage of women with a live birth who participated in binge drinking during 3 months before pregnancy	—
	Percentage of women with a live birth who reported smoking was allowed in the home	Household smoke exposure
		Other indicators of substance use: marijuana, illegal drugs, and drug rehabilitation program
Nutrition and physical activity	Percentage of women who consume at least five daily servings of fruits and vegetables	Number of servings of fruits and vegetables (excluding potatoes) on 24-hour dietary recall
	Percentage of women who are overweight or obesity	Measured weight and height (kg/m²)
	Percentage of women with a live birth who were overweight or obesity at time of getting pregnant	—
	Percentage of women with a live birth who took folic acid, multivitamin, or prenatal vitamin every day during month before pregnancy	Multivitamin (contains two or more vitamins/minerals) use in previous 30 days
	Percentage of women who meet physical activity recommendations (150 minutes/week)	Number of minutes per week spent doing moderate- and vigorous-intensity recreational activities
		Average weeknight sleep duration (hours)
Mental health	Percentage of women who reported mental health was not good at least 14 of past 30 days	Patient Health Questionnaire-9, depression screening instrument
	Percentage of women with a live birth who visited health care provider for anxiety/depression during year before pregnancy	—
	Percentage of women with a live birth who experienced postpartum depression	—
Emotional support	Percentage of women with a live birth who were physically abused in year before pregnancy	—
	Percentage of women with a live birth who were mentally abused in year before pregnancy	—
	Percentage of women who always or usually get social and emotional support	—
	Percentage of women with a live birth who report adequate social and emotional support	—
Chronic conditions	Percentage of women who were ever told by health care provider that they have diabetes	Ever been told by a doctor that have diabetes or sugar diabetes
	Percentage of women with a live birth who were ever told by health care provider that they have diabetes before pregnancy	—
	Percentage of women who were ever told by health care provider that they have hypertension	Ever been told by a doctor that have high blood pressure
	Percentage of women with a live birth who were ever told by health care provider that have hypertension before pregnancy	—
	Percentage of women who have asthma	Ever been told by a doctor that have asthma
Infections	Percentage of women with a live birth who were tested for HIV within year before pregnancy	Ever tested for HIV
	Rates of chlamydia, gonorrhea, and syphilis	Ever told that have chlamydia, gonorrhea, or genital warts
	Percentage of women who received influenza vaccination within previous year	—

NHANES, National Health and Nutrition Examination Survey; PCH, preconception health.

General health status and life satisfaction

Self-rated their general health status as excellent/very good, good, fair, or poor.

Social determinants of health

Highest achieved educational level (less than high school, high school graduate, college graduate or higher) and household income at or below 200% of the Federal Poverty Threshold (yes or no).

Health care

Current type of health insurance (private, public, none/other); timing of the most recent health care visit (within the previous year; yes or no); and timing of the most recent dental visit (<1 year, 1–3 years, >3 years).

Reproductive health and family planning

Several of the preconception health indicators within this domain, such as previous birth outcomes and pregnancy intendedness, were part of restricted use data or not collected by NHANES. Instead, we examined available factors related to women's reproductive and preconception health: women reported on ever using birth control (yes or no); having a regular period during the previous year (yes or no); seeing a physician because they were unable to become pregnant (yes or no); and trying to become pregnant for at least a year (yes or no).

Tobacco, alcohol, and substance use

Reported cigarette smoking (current, former, and never); exposure to secondhand smoking (current smoker, nonsmoker with exposure, and nonsmoker with no exposure); frequency of alcohol consumption during the past year (less than once per week, one to two times per week, and three or more times per week); and binge drinking (defined as number of days in the previous month when consumed more than four drinks in one sitting; none or 1 or more days). Within this domain, we also examined reported ever use of marijuana (yes or no), illegal drugs (i.e., cocaine, heroin, methamphetamines, and injected drugs; yes or no), or a drug treatment or drug rehabilitation program (yes or no).

Mental health

Women completed the Patient Health Questionnaire-9 (PHQ-9, total points = 27) to assess depressive symptoms during the previous 2 weeks and were categorized as having none/minimal depressive symptoms (0–4 points), mild depressive symptoms (5–9 points), and moderate/severe depressive symptoms (≥10 points).²¹ Women also reported if they had seen a mental health professional within the previous year (yes or no). This information was used as a surrogate for the preconception health indicator of reporting mental health as not good for 14 of the past 30 days.

Nutrition and physical activity

Daily intakes of fruits and vegetables (five or more servings per day, excluding white potatoes; yes or no) were calculated from one 24-hour food recall administered during the in-person interview. Body mass index (BMI, kg/m²) was derived from weight and height measured by NHANES staff at an in-person medical examination and categorized as healthy (<25 kg/m²), overweight (25 to <30 kg/m²), and obese (≥30 kg/m²). The few women with underweight BMI (<18.5 kg/m²; n = 113, 3%) were included in the healthy weight category. Physical activity was calculated based on questions asking the amount of time and frequency spent doing moderate and vigorous recreational activities during the previous 7 days.

This variable was dichotomized based on the preconception health indicator of meeting recommended levels of at least 150 minutes of moderate and/or vigorous recreational physical activities per week (yes or no).⁴ Multivitamin use, defined as taking a least one supplement containing two or more vitamins during the previous month (yes or no), was used as a surrogate for the preconception health indicator of “daily multivitamin/prenatal vitamin/folic acid supplementation in the month prior to pregnancy.” Additionally, we examined self-reported number of hours of weeknight sleep (short, <7 hours; ideal, 7–9 hours; and long, >9 hours) because sleep is an important health behavior linked to women's reproductive health and numerous chronic medical conditions.^22
–24

Chronic conditions

Women reported whether a doctor had ever told them that they had diabetes (yes/borderline or no), hypertension (yes or no), and asthma (yes or no).

Infections

Women reported whether they had ever been tested for HIV (yes or no) and whether they had ever been told by a doctor that they had chlamydia, gonorrhea, or genital warts (yes or no, only available in NHANES 2013–2014 and 2015–2016).

Other sociodemographic characteristics

Women self-reported their age (years), race/ethnicity (non-Hispanic white, non-Hispanic black, Mexican American, other Hispanic, and other race/ethnicity), and marital status (single or married/living with partner). Gravidity (never pregnant, one to two pregnancies, three or more pregnancies) and current pregnancy status (based on a urine test or self-report; yes or no) were only publicly available among women aged 20 years and older.

Statistical analyses

All analyses were conducted using Stata version 15.1 (College Station, TX, USA) and were statistically weighted for the complex survey design of NHANES using survey data commands (svy). For descriptive analyses, we calculated unweighted counts, survey weighted counts, survey weighted means with standard errors (SE, continuous variables), and survey weighted proportions (categorical variables). Bivariate associations of disability status (no disabilities, any self-reported disabilities, only one type of disability, and two or more types of disabilities) and preconception health indicators were tested using chi-square tests (categorical variables) and t-tests (continuous variables). Poisson regression models estimated associations (prevalence ratios [PRs] and 95% confidence intervals [CIs]) between disability status and preconception health indicators.

Disability status was included in models as a dichotomous variable (any disabilities compared with no disabilities) and as categories (only one type of disability and two or more types of disabilities compared with no disabilities). Covariate selection was based on those identified from the previous literature.^10,11 Models were adjusted for age, race/ethnicity, education, marital status, and health insurance status (when applicable). Household income status was missing for ∼10% of the sample. We examined models with and without adjustment for household income status and found no appreciable differences in the magnitude or precision of effect estimates; therefore, household income was not included in final regression models.

There were 176 (5%) women who were pregnant at the time of data collection; these women were included in analyses because they were of reproductive age and the majority of the preconceptional health indicators are independent of pregnancy status. However, because pregnancy may be related to health behaviors and access to health care, we conducted sensitivity analyses excluding these women. Finally, we conducted the Bonferroni correction based on the number of hypotheses being tested (calculated as α = 0.05/31 = 0.0016) to account for multiple comparisons. Models with p-values less than the Bonferroni-corrected significance level threshold of 0.0016 are denoted in the results.

Results

There were 4055 women aged 18–44 years who participated in NHANES 2013–2018 and met the inclusion criteria. Fifteen percent (n = 601) of all women reported having any disability. Among those with any disability, 381 (9%) reported having only 1 type of disability and 220 (6%) reported having 2 or more types of disabilities. Women with any disabilities were more likely to be single and have at least one previous pregnancy compared with women with no disabilities; no differences were observed for race/ethnicity (Table 2). On average, women with one disability were slightly younger [weighted mean (SE): 29.5 (0.52) years] than women with no disabilities [weighted mean (SE): 30.8 (0.21) years], whereas women with two or more disabilities were slightly older [weighted mean (SE): 31.5 (0.71) years].

Table 2.

Distributions of Sociodemographic Characteristics and Preconceptional Health Indicators of Women of Reproductive age (18–44 years) by Self-Reported Disability Status (Categorized as No Disabilities, Any Disabilities, Only One Disability, and Two or More Disabilities), National Health and Nutrition Examination Surveys 2013–2018 (Unweighted n = 4055)

	No self-reported disabilities		Any self-reported disabilities			One type of self-reported disability			Two or more types of self-reported disabilities
	n	%^a	n	%	p ^b	n	%	p ^b	n	%	p ^b	p ^c
Total	3454	85	601	15		381	9		220	6
Age, mean and SE	30.8	0.21	30.2	0.50	0.27	29.5	0.52	0.02	31.5	0.71	0.27	0.01
Age (years)	3454		601		0.05	381		0.02	246		0.08	0.04
18–25	1096	30	204	36		142	39		62	31
26–35	1271	38	180	32		118	34		62	30
36–44	1087	32	217	32		121	28		96	39
Race/ethnicity	3454		601		0.40	381		0.51	220		0.19	0.31
Non-Hispanic white	1016	53	215	56		122	53		93	60
Non-Hispanic black	762	14	133	14		86	14		47	13
Mexican American	598	12	114	14		80	15		34	12
Other Hispanic	391	9	56	7		36	7		20	6
Other	687	12	83	10		57	11		26	9
Marital status	3454		601		0.007	381		0.02	220		0.04	0.74
Single	1658	43	335	51		208	50		127	52
Married or living with partner	1826	57	266	49		173	50		93	48
Currently pregnant^d	3061		526		0.10	327		0.32	199		0.05	0.14
Yes	161	5	15	3		NR			NR
No	2900	95	511	97		NR			NR
Gravidity^d	3045		567		0.05	345		0.10	222		0.10	0.65
Never pregnant	1131	33	175	25		120	25		55	25
One to two pregnancies	877	33	143	35		87	36		56	33
Three or more pregnancies	1037	34	249	40		138	38		111	42
Self-reported general health status	2979		565		<0.0001	342		<0.0001	223		<0.0001	0.13
Excellent or very good	1275	49	95	20		71	21		24	16
Good	1245	39	226	43		145	46		81	39
Fair	417	11	206	31		113	28		93	37
Poor	42	1	38	6		13	5		25	8
Education	3446		599		<0.0001	380		<0.0001	219		<0.0001	0.46
<High school	535	11	177	24		110	23		67	25
High school graduate	1970	55	357	62		222	61		135	63
College graduate or higher	941	34	65	14		48	16		17	12
Household income	3099		548		<0.0001	346		<0.0001	202		<0.0001	0.15
≤200% Federal poverty threshold	1604	41	393	64		235	61		158	70
>200% Federal poverty threshold	1495	59	155	36		111	39		44	30
Insurance status	3422		592		<0.0001	378		<0.0001	214		<0.0001	0.09
Private	1870	63	194	40		145	44		49	32
Public	797	19	237	35		131	32		106	41
None or other	755	18	161	25		102	24		59	27
Most recent health care visit	3445		593		0.004	380		0.18	213		0.01	0.13
≤1 Year ago	2985	88	536	92		337	90		199	95
>1 Year ago	460	12	57	8		43	10		14	5
Most recent dental visit	3447		601		0.0001	381		0.03	220		0.0001	0.27
<1 Year ago	2062	62	285	49		191	53		94	44
1–3 Years ago	782	22	161	24		100	23		61	25
>3 Years ago or never	603	17	155	27		90	24		65	31
Ever taken birth control	2971		562		0.76	342		0.92	220		0.35	0.33
Yes	1841	71	372	72		224	70		148	74
No	1130	29	190	28		118	30		72	26
Had regular periods in the past year	2894		524		0.36	329		0.21	195		0.54	0.20
Yes	2722	93	483	92		302	90		181	94
No	172	7	41	8		27	10		14	6
Saw physician because unable to become pregnant	2894		524		0.89	329		0.48	195		0.31	0.14
Yes	177	8	41	8		24	6		17	11
No	2717	92	483	92		305	94		178	89
Tried for ≥1 year to become pregnant	2893		524		0.005	329		0.07	195		0.02	0.40
Yes	266	10	88	15		50	14		30	17
No	2627	90	444	85		279	86		165	83
Smoking	3452		601		<0.0001	381		<0.0001	220		<0.0001	0.61
Current	365	12	144	27		85	25		59	30
Former	426	15	92	17		54	17		38	16
Never	2661	73	365	56		242	58		123	54
Exposed to household secondhand smoke	3343		589		<0.0001	373		<0.0001	216		<0.0001	0.17
Current smoker	365	12	144	27		85	26		59	30
Nonsmoker, exposed to secondhand smoke	176	5	45	6		25	5		20	8
Nonsmoker, not exposed to secondhand smoke	2802	83	400	66		263	69		137	61
Alcohol consumption in the past year	2895		526		0.42	329		0.42	197		0.64	0.70
Never	824	22	174	26		112	27		62	25
<1 Time/week	1494	52	258	51		161	50		97	52
1–2 Times/week	396	17	59	15		38	16		21	13
≥3 Times/week	181	8	35	8		18	7		17	10
Binge drinking, number of times in past 30 days	2936		530		0.02	333		0.01	197		0.41	0.84
Nondrinkers	824	22	174	26		112	27		62	25
None	1846	67	288	59		177	58		111	61
≥1	266	11	68	15		44	15		24	14
Ever used marijuana	2858		507		0.01	317		0.17	190		0.02	0.25
Yes	1369	54	287	61		174	59		113	65
No	1489	46	220	39		143	41		77	35
Ever used illegal drugs	2857		505		0.0004	316		0.001	189		0.04	0.93
Yes	243	11	85	17		49	17		36	18
No	2614	89	420	83		267	83		153	82
Ever attended drug rehabilitation program	2857		506		0.0002	316		0.02	190		0.0001	0.03
Yes	69	3	39	7		18	5		21	11
No	2788	97	467	93		298	95		169	89
Number of daily fruit and vegetable servings	2978		529		0.47	337		0.69	192		0.01	0.44
<5	2820	94	506	95		NR^g			NR^g
≥5	158	6	23	5		NR^g			NR^g
BMI status	3266		570			367			203
BMI, mean and SE	28.7	0.22	31.6	0.50	<0.0001	30.8	0.46	<0.0001	32.9	1.07	<0.0001	0.08
Underweight or healthy weight	1253	38	167	32	<0.0001	108	32	0.01	59	32	<0.0001	0.02
Overweight	823	26	114	18		87	22		27	11
Obese	1190	36	289	50		172	46		117	57
Took multivitamin in previous 30 days	1686		284		0.001	178		0.22	106		<0.0001	0.002
Yes	1073	64	139	48		96	57		43	34
No	613	36	145	52		82	43		63	66
Met physical activity recommendations^e	3454		601		<0.0001	394		0.03	246		0.0001	0.06
Yes	1249	40	159	30		114	34		45	24
No	2205	60	442	70		267	66		175	76
Average weeknight sleep duration	3449		599		<0.0001	380		0.0001	219		<0.0001	0.32
<7 Hours	876	23	167	26		98	25		69	28
7–9 Hours	2263	69	330	57		222	60		108	53
>9 Hours	310	8	102	16		60	15		42	19
Depressive symptoms	2897		521		<0.0001	328		<0.0001	193		<0.0001	0.02
None or minimal	2278	79	210	38		154	44		56	28
Mild	459	15	141	27		86	26		55	29
Moderate or severe	160	6	170	35		88	30		82	44
Saw a mental health provider in past year	3453		601		<0.0001	381		<0.0001	220		<0.0001	0.003
Yes	249	8	169	30		90	26		79	39
No	3204	92	432	70		291	74		141	61
Self-reported diabetes	3452		639		<0.0001	381		0.004	219		<0.0001	0.003
Yes	126	3	68	11		32	7		36	16
No	3326	97	532	89		349	93		183	84
Self-reported hypertension	3452		601		<0.0001	381		<0.0001	220		<0.0001	0.0003
Yes	365	10	134	22		64	17		70	31
No	3087	90	467	78		317	83		150	69
Self-reported asthma	3451		597		0.0001	378		0.01	219		<0.0001	0.02
Yes	538	17	146	27		82	23		64	33
No	2913	83	451	73		296	77		155	67
Ever tested for HIV	1854		351		0.14	212		0.07	139		0.58	0.31
Yes	947	53	177	46		109	44		74	50
No	907	47	174	54		103	56		65	50
Ever diagnosed with STI^f	1873		298		0.002	327		0.02	221		0.02	0.65
Yes	92	6	31	14		17	13		14	16
No	1781	94	267	86		171	87		96	84

All percentages are weighted for the NHANES design.

p-Value comparing to women with no self-reported disabilities.

p-Value comparing to women with one self-reported disability.

Pregnancy information was not available for women aged 18 and 19 years.

Defined as ≥150 minutes of moderate and vigorous physical activity per week.

Only included in NHANES 2013–2016.

NR due to cell sizes <10.

SE, standard error; NR, not reported; BMI, body mass index; HIV, human immunodeficiency virus; STI, sexually transmitted infection.

Distributions of preconception health indicators varied by disability status (Table 2). Greater proportions of women with any disabilities had poor or fair self-rated health; did not graduate high school; had household incomes at or below 200% of the Federal Poverty Threshold; had no health insurance; had a health care visit within the previous year; and did not have a dental visit within the previous 3 years (p < 0.05 for all comparisons). For reproductive health, substance use, and nutritional indicators, greater proportions of women with any disabilities tried to become pregnant for a year or more; were current smokers; engaged in binge drinking; ever used marijuana and illegal drugs; ever attended a drug rehabilitation program; had obesity; did not take a multivitamin; were physically inactive; and had short or long sleep durations (p < 0.05 for all comparisons).

For mental health, medical conditions, and infections, women with any disabilities were more likely to report mild-to-severe depressive symptoms; seeing a mental health care provider; ever being told by a physician that they had diabetes, hypertension, and asthma; and ever having a sexually transmitted infection (p < 0.05 for all comparisons). Differences were observed when comparing preconceptional health indicators between women with two or more types of disabilities with those with only one type of disability. Greater proportions of women with two or more types of disabilities had ever attended a drug rehabilitation program; obesity; no multivitamin use; moderate-to-severe depression; seen a mental health provider; and ever been told they had diabetes, hypertension, and asthma compared with women with only one disability (p < 0.05 for all comparisons).

In Poisson regression models (Table 3), the majority of observed disparities in preconception health indicators by disability status remained after adjustment for covariates. For women with any self-reported disabilities compared with those with no disabilities, adjusted prevalence ratios (aPRs) ranged from ∼1.1 to 2.0 for indicators of less than high school education, household income below 200% of the Federal Poverty Threshold, recent health care visit (≤1 year), no recent dental visit (>3 years), difficulty getting pregnant, current smoking, binge drinking, ever used illegal drugs, attended drug rehabilitation, obesity, no multivitamin use, physical inactivity, long sleep durations, hypertension, asthma, and sexually transmitted infections.

Table 3.

Unadjusted and Adjusted Prevalence Ratios for Preconception Health Indicators and Self-Reported Disability Status Among Women of Reproductive Age (18–44 years), National Health and Nutrition Examination Surveys, 2013–2018

Preconception health indicator	n	Any disabilities^a				Only one type of disability^a				Two or more types of disabilities^a
		Unadjusted		Adjusted^b		Unadjusted		Adjusted^b		Unadjusted		Adjusted^b
		PR	95% CI	PR	95% CI	PR	95% CI	PR	95% CI	PR	95% CI	PR	95% CI
General health status and life satisfaction
Poor or fair health (reference: good/very good/excellent)	3385	3.12^g	2.67–3.64	2.38^g	1.99–2.85	2.69^g	2.24–3.23	2.13^g	1.72–2.64	3.82^g	3.11–4.69	2.78^g	2.26–3.43
Social determinants of health
<High school^c	4004	2.16^g	1.80–2.59	1.68^g	1.43–1.96	2.05^g	1.64–2.55	1.64^g	1.33–2.00	2.35^g	1.77–3.10	1.74^g	1.35–2.24
Household income ≤200% Federal Poverty Threshold	3609	1.56^g	1.39–1.74	1.12	1.00–1.24	1.48^g	1.32–1.67	1.09	0.98–1.21	1.68^g	1.42–2.00	1.16	1.00–1.33
Health care
No health insurance^d	4004	1.36	1.09–1.71	1.13	0.90–1.42	1.30	0.99–1.70	1.08	0.82–1.41	1.48	1.07–2.04	1.24	0.89–1.73
Most recent health care visit, ≤1 year^d	3988	1.04	1.02–1.07	1.06^g	1.03–1.09	1.03	0.99–1.07	1.04	1.00–1.09	1.08^g	1.03–1.12	1.10^g	1.05–1.15
Most recent dental visit, 1–3 years (reference: <1 year)	3250	1.26	1.04–1.52	1.07	0.89–1.30	1.18	0.92–1.51	1.02	0.79–1.31	1.40	1.07–1.84	1.17	0.92–1.50
Most recent dental visit, >3 years (reference: <1 year)	3068	1.68^g	1.34–2.10	1.29	1.04–1.59	1.50	1.09–2.06	1.19	0.88–1.61	1.98^g	1.51–2.61	1.45	1.14–1.84
Reproductive health and family planning
Never taken birth control	3376	0.96	0.76–1.22	0.83	0.66–1.05	1.02	0.76–1.33	0.87	0.68–1.11	0.87	0.66–1.14	0.78	0.59–1.03
Did not have regular periods in past year	3380	1.24	0.78–1.97	1.16	0.75–1.79	1.47	0.80–2.71	1.39	0.78–2.47	0.86	0.50–1.49	0.78	0.43–1.39
Saw physician because unable to become pregnant	3380	1.04	0.65–1.68	1.37	0.84–2.22	0.83	0.48–1.43	1.10	0.64–1.87	1.40	0.75–2.62	1.83	0.94–3.59
Tried ≥1 year to become pregnant	3379	1.48	1.14–1.91	1.59	1.23–2.05	1.34	0.98–1.83	1.51	1.11–2.06	1.70	1.11–2.61	1.71	1.10–2.66
Tobacco, alcohol, and substance use
Current smoker	4002	2.28^g	1.81–2.87	1.48^g	1.21–1.82	2.12^g	1.71–2.64	1.50^g	1.21–1.86	2.54^g	1.79–3.60	1.45	1.07–1.97
Exposed to secondhand smoke in the home, nonsmoker (reference: not exposed, nonsmoker)	3379	1.52	0.88–2.63	1.21	0.74–1.98	1.25	0.67–2.32	1.01	0.57–1.79	2.00	1.04–3.83	1.57	0.87–2.83
Alcohol consumption, ≥3 times/week	3382	0.94	0.59–1.49	1.21	0.79–1.85	0.80	0.45–1.40	1.05	0.61–1.82	1.17	0.60–2.27	1.46	0.77–2.77
Binge drinking ≥1 time in past 30 days	3426	1.34	0.98–1.84	1.46	1.08–1.98	1.40	1.02–1.91	1.49	1.09–2.05	1.26	0.76–2.08	1.41	0.87–2.29
Ever used marijuana	3328	1.12	1.02–1.23	1.10	0.99–1.21	1.09	0.97–1.22	1.07	0.94–1.21	1.18	1.03–1.35	1.15	1.00–1.32
Ever used illegal drugs	3325	1.61^g	1.25–2.06	1.42	1.10–1.83	1.60^g	1.23–2.07	1.44	1.10–1.88	1.62	1.02–2.58	1.38	0.86–2.23
Ever attended drug rehabilitation program	3326	2.54^g	1.60–4.05	1.72	1.08–2.74	1.80	1.09–2.98	1.30	0.76–2.24	3.75^g	2.05–6.89	2.32	1.29–4.20
Nutrition and physical activity
<5 Daily servings of fruits and vegetables	3466	1.02	0.99–1.05	1.00	0.97–1.03	1.00	0.96–1.04	0.99	0.94–1.03	1.05	1.03–1.07	1.03	1.01–1.05
Obesity	3792	1.41^g	1.25–1.59	1.32^g	1.17–1.48	1.29^g	1.11–1.50	1.23	1.06–1.43	1.61^g	1.37–1.90	1.46^g	1.23–1.75
No multivitamin in past 30 days	1712	1.45^g	1.20–1.74	1.38^g	1.16–1.66	1.18	0.90–1.55	1.15	0.89–1.49	1.86^g	1.56–2.21	1.75^g	1.44–2.13
Did not meet physical activity recommendations^e	4004	1.17^g	1.11–1.24	1.07	1.01–1.14	1.11	1.02–1.21	1.04	0.94–1.14	1.27^g	1.16–1.39	1.13	1.03–1.24
<7 Hours sleep per night (reference: 7–9 hours)	3593	1.23	1.06–1.43	1.16	0.99–1.36	1.17	0.95–1.44	1.12	0.91–1.37	1.35	1.07–1.70	1.24	0.97–1.57
>9 Hours sleep per night (reference: 7–9 hours)	2966	2.34^g	1.82–3.01	1.82^g	1.35–2.44	2.10^g	1.53–2.88	1.62	1.13–2.33	2.76^g	2.03–3.75	2.18^g	1.53–3.10
Mental health
Mild-to-severe depression	3380	2.94^g	2.62–3.29	2.62^g	2.34–2.93	2.64^g	2.31–3.03	2.40^g	2.09–2.75	3.43^g	3.01–3.91	3.00^g	2.63–3.42
Saw mental health provider in past year	4003	3.63^g	2.89–4.55	3.76^g	3.00–4.69	3.01^g	2.33–3.90	3.15^g	2.45–4.03	4.67^g	3.63–6.01	4.87^g	3.82–6.21
Chronic conditions
Diabetes	4001	3.16^g	2.16–4.61	3.19^g	2.21–4.60	2.21	1.30–3.74	2.33	1.38–3.94	4.78^g	3.14–7.28	4.67^g	3.11–7.02
Hypertension	4002	2.27^g	1.83–2.82	2.02^g	1.59–2.55	1.74^g	1.37–2.21	1.67^g	1.29–2.17	3.18^g	2.45–4.14	2.54^g	1.85–3.48
Asthma	3998	1.63^g	1.29–2.04	1.54^g	1.20–1.98	1.40	1.08–1.81	1.33	1.02–1.73	2.01^g	1.52–2.66	1.92^g	1.39–2.65
Infections
Ever tested for HIV	2181	0.88	0.74–1.05	0.89	0.75–1.06	0.84	0.68–1.03	0.87	0.72–1.05	0.95	0.77–1.18	0.92	0.73–1.15
Ever diagnosed with STI^f	2063	2.27	1.31–3.93	1.92	1.16–3.16	2.21	1.18–4.14	1.94	1.13–3.34	2.37	1.01–5.54	1.88	0.86–4.10

Reference is women with no self-reported disabilities.

Adjusted models include age, race/ethnicity, education, marital status, and health insurance status.

Model not adjusted for education.

Model not adjusted for health insurance.

Defined as ≥150 minutes of moderate and vigorous physical activity per week.

Only included in NHANES 2013–2016.

Bonferroni-corrected p-value <0.0016.

CI, confidence interval; PR, prevalence ratio.

The greatest disparities between women with and without disabilities were observed for indicators of self-rated poor or fair general health, poor mental health, and diabetes, with aPRs ranging from ∼2.4 to 3.8. In models that compared categories of number of types of self-reported disabilities, aPRs were generally similar for women with only one type of disability and women with two or more types of disabilities when compared with women with no disabilities. Some exceptions were observed, with higher prevalence estimates for poor general and mental health, drug rehabilitation, and chronic medical conditions among women with two or more types of disabilities. In sensitivity analyses, we did not observe any differences in magnitude or precision of effect estimates after excluding women who were currently pregnant; therefore, we present models with the entire sample.

Discussion

Among a large, nationally representative sample of U.S. women of reproductive age, we found that 15% reported any disability, of which 6% reported having two or more types of disabilities. Disability status was associated with many suboptimal preconception health indicators. Compared with women with no disabilities, women with any self-reported disabilities were more likely to report poor or fair general health, lower education and household income status, no recent dental visit, difficulty getting pregnant, current smoking, binge drinking, drug use and rehabilitation, obesity, no multivitamin use, physical inactivity, long sleep durations, poor mental health, chronic medical conditions, and sexually transmitted infections.

Associations between disability status and preconception health indicators were generally similar when comparing women with only one type of disability and women with two or more types of disabilities with those with no disabilities; greater prevalence were observed for some indicators, including poor general and mental health, drug rehabilitation, and chronic medical conditions, among women with two or more types of disabilities.

Pregnant women with disabilities experience high rates of many complications, including infections and cesarean delivery, as well as poor birth, infant, and postpartum outcomes such as preterm birth, low birth weight, and extended postdelivery hospital stays.^16
–18 Although these adverse outcomes may, in part, be attributed to disability-specific medical complexities (e.g., spinal cord injuries), it is plausible that disparities in preconception health indicators also have contributing roles.^7,10,11 Poor self-rated general and mental health, chronic medical conditions, smoking, alcohol use, and physical inactivity are reported among women of reproductive age with disabilities.^7,10,11 They are also more likely to feel unsafe,⁷ experience stressful life events,⁷ and suffer from physical abuse,²⁵ and they are less likely to receive a regular Pap test.¹⁰

Findings from the current study confirm and add to the existing literature, highlighting disparities related to substance use, oral health, sleep, sexual health, and fertility, particularly among women who reported two or more types of disabilities. Associations of disability and preconception health may also be compounded by factors related to social determinants of health.

In an analysis of the 2016 BRFSS, Horner-Johnson et al. found that the prevalence of several preconception health indicators varied by women's disability status and race/ethnicity.¹⁰ Obesity and physical inactivity disparately affected non-Hispanic black women with disabilities compared with women with only one of these characteristics (i.e., black women without disabilities or white women with disabilities). Other indicators, such as current smoking, were lower among Hispanic women with disabilities compared with non-Hispanic white women with disabilities.¹⁰

Reproductive health among women with disabilities remains understudied, particularly with respect to barriers that may lead to disparate outcomes. Social determinants of health, such as poverty, lower educational attainment, and discrimination, likely impact women's ability to seek and receive reproductive health care. Disability-based discrimination is prevalent among adolescents and young adults and has been associated poor self-rated health and psychological distress, especially among individuals with severe physical or intellectual impairments.²⁶ Research is needed to understand the intersection of these social factors and their influence on women's access to and utilization of health care, lifestyle behaviors, and health outcomes.

There is long-standing knowledge that poor physical and mental health during the reproductive years is predictive of short- and long-term consequences for women (and men) and their offspring.^2,27 Despite preconception care and health being included in national and organizational recommendations, such as the U.S. Healthy People objectives and the American Academy of Pediatrics/American College of Obstetricians and Gynecologists “Guidelines for Perinatal Care,” the health care community has traditionally prioritized prenatal and infant care over preconception care.^1,28 For women with disabilities, preconception care may further be disregarded by clinicians due to common misconceptions that these women do not engage in sexual activity or are unable or not intending to have children.²⁹

Interventions and policy efforts that target women during the immediate preconception period, such as increasing health care visits, preventative screenings, and counseling on lifestyle behaviors (e.g., physical activity, diet, and substance use), may help to reduce health disparities encountered by women with disabilities as well as other women affected by structural and societal inequities. However, preconception health is not solely reflective of health during the few months before pregnancy but comprises an accumulation of experiences and exposures from early life through adolescence.³ Efforts made to improve preconception health, particularly among women with disabilities, should incorporate a life course approach addressing social, environmental, and medical-related issues well before the reproductive years.³

Mitra et al. developed a perinatal health framework for women with physical disabilities, incorporating individual factors (e.g., demographic factors, health conditions), mediating factors (e.g., health care-related, psychosocial, social support factors), and environmental contexts (e.g., cultural norms, physical environment, laws/policies) confronted throughout the life span that contribute to maternal and infant health outcomes.³⁰ The framework identified specific needs and obstacles encountered by women with disabilities and can be used to facilitate efforts to enhance surveillance, research, interventions, and clinical practice.³⁰ An example of a recent enhancement made to U.S. maternal and infant health surveillance was the addition of the Washington Group disability questions to PRAMS in 2019.

These questions take ∼90 seconds to complete and assess both disability type and severity, allowing researchers to investigate a range of factors affecting women with disabilities before, during, and after pregnancy.³¹ Although the Department of Health and Human Services adopted data collection standards on disability status for use in national population health surveys beginning in 2011 (based on section 4302 of the Affordable Care Act), reaching full compliance has been slow.³² In addition to national and federally funded surveillance, it should become common practice to include questions about disability status in reproductive, maternal, and child health surveys and assessments, as well as other epidemiological studies (e.g., birth cohorts), when applicable.

Other strategies to reduce health disparities among women with disabilities center on improving their interactions within the health care system. Currently, most health care organizations do not systematically document patients' disability status, limiting organizations' ability to provide suitable accommodations and track quality of care and health care needs.^33,34 Routine assessment of type and severity of functional limitations, especially since women may have several types of limitations, should be included with general clinical care and the electronic health record system. Clinicians and other practitioners also require structured training about how to deliver appropriate preventive screenings, medical care, and counseling to all individuals with disabilities.³⁵

Women with disabilities may need to interact with numerous types of providers regarding issues related to, for example, mental health, physical therapy, fertility, chronic medical conditions, and substance/drug use. Disability competencies have been developed and should be added to educational curricula for all types of health care practitioners (e.g., clinicians, social workers, and public health administrators) and policy makers.^36
–38 Addressing these issues could have a substantial impact on fostering trusting relationships between women with disabilities and their health care providers and improving women's health from an early age.

Strengths of this study include the use of data from a nationally representative sample of women of reproductive age in the U.S.

Data collection included detailed information on many important indicators identified by the 2007 Working Group. We examined these indicators by number of reported disabilities (none, one type of disability, and two or more types of disabilities). Limitations include the cross-sectional study design and reliance on self-reported information for the majority of study variables. Questions on disability status were not discerning regarding specific cause or severity of disability.

In NHANES, participants were only queried about having serious difficulty with functional domains (yes or no), which differs from the Washington Group questions that ask about level of severity (no difficulty, some difficulty, a lot of difficulty, cannot do at all). Questions regarding sensory disabilities did not differentiate between subgroups; for example, there may be important differences between individuals who identify as deaf compared with those who identify as having serious difficulty hearing.³⁹ We were also limited by sample size and may have been underpowered to detect associations for disability status when categorized by number of types of disabilities. Additionally, we were unable to examine associations of disability and preconceptional health stratified by specific type of disability or other important socioeconomic factors.

Conclusions

We leveraged recent data from a nationally representative sample of women of reproductive age and found that women with disabilities reported suboptimal health for the majority of preconception health indicators compared with women without disabilities. Further investigation is required to understand how social determinants of health contribute to these disparities. Preventive strategies to improve reproductive health among women with disabilities include adequate access to health care, interventions targeting lifestyle and health behaviors, and education and training programs for all health practitioners.

Authors Disclosure Statement

No competing financial interests exist.

Funding Information

This project was supported in whole by a grant from the New York University Research Challenge Fund Program.

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Preconception Health and Disability Status Among Women of Reproductive Age Participating in the National Health and Nutrition Examination Surveys,2013–2018

Abstract

Background:

Materials and Methods:

Results:

Conclusions:

Introduction

Materials and Methods

Disability status

Preconception health indicators

General health status and life satisfaction

Social determinants of health

Health care

Reproductive health and family planning

Tobacco, alcohol, and substance use

Mental health

Nutrition and physical activity

Chronic conditions

Infections

Other sociodemographic characteristics

Statistical analyses

Results

Discussion

Conclusions

Authors Disclosure Statement

Funding Information

References