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Clinical
Preventive
Services
for Women
Closing the Gaps
Committee on Preventive Services for Women
Board on Population Health and Public Health Practice
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Govern-
ing Board of the National Research Council, whose members are drawn from the
councils of the National Academy of Sciences, the National Academy of Engineer-
ing, and the Institute of Medicine. The members of the committee responsible for
the report were chosen for their special competences and with regard for appropri-
ate balance.
This study was supported by Contract HHSP23337013T between the National
Academy of Sciences and the U.S. Department of Health and Human Services. Any
opinions, findings, conclusions, or recommendations expressed in this publication
are those of the authors and do not necessarily reflect the view of the organizations
or agencies that provided support for this project.
International Standard Book Number-13: 978-0-309-21538-1
International Standard Book Number-10: 0-309-21538-2
Additional copies of this report are available from the National Academies Press,
500 Fifth Street NW, Lockbox 285, Washington, DC 20055; (800) 624-6242 or
(202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.
edu.
For more information about the Institute of Medicine, visit the IOM home page
at: www.iom.edu.
Copyright 2011 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost
all cultures and religions since the beginning of recorded history. The serpent ad-
opted as a logotype by the Institute of Medicine is a relief carving from ancient
Greece, now held by the Staatliche Museen in Berlin.
Cover credit: The cover painting is reprinted with permission from the artist,
Alberto Schunk.
Suggested citation: IOM (Institute of Medicine). 2011. Clinical Preventive Services
for Women: Closing the Gaps. Washington, DC: The National Academies Press.
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
— Goethe
Advising the Nation. Improving Health.
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The National Academy of Sciences is a private, nonprofit, self-perpetuating society
of distinguished scholars engaged in scientific and engineering research, dedicated to
the furtherance of science and technology and to their use for the general welfare.
Upon the authority of the charter granted to it by the Congress in 1863, the Acad-
emy has a mandate that requires it to advise the federal government on scientific
and technical matters. Dr. Ralph J. Cicerone is president of the National Academy
of Sciences.
The National Academy of Engineering was established in 1964, under the charter
of the National Academy of Sciences, as a parallel organization of outstanding en-
gineers. It is autonomous in its administration and in the selection of its members,
sharing with the National Academy of Sciences the responsibility for advising the
federal government. The National Academy of Engineering also sponsors engineer-
ing programs aimed at meeting national needs, encourages education and research,
and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi-
dent of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of
Sciences to secure the services of eminent members of appropriate professions in
the examination of policy matters pertaining to the health of the public. The Insti-
tute acts under the responsibility given to the National Academy of Sciences by its
congressional charter to be an adviser to the federal government and, upon its own
initiative, to identify issues of medical care, research, and education. Dr. Harvey V.
Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sci-
ences in 1916 to associate the broad community of science and technology with the
Academy’s purposes of furthering knowledge and advising the federal government.
Functioning in accordance with general policies determined by the Academy, the
Council has become the principal operating agency of both the National Academy
of Sciences and the National Academy of Engineering in providing services to the
government, the public, and the scientific and engineering communities. The Coun-
cil is administered jointly by both Academies and the Institute of Medicine. Dr.
Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of
the National Research Council.
www.national-academies.org
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COMMITTEE ON PREVENTIVE SERVICES FOR WOMEN
Linda Rosenstock (Chair), Dean, School of Public Health, University of
California, Los Angeles
Alfred O. Berg, Professor, Department of Family Medicine, University of
Washington School of Medicine, Seattle
Claire D. Brindis, Professor of Pediatrics and Health Policy, Department
of Pediatrics and Department of Obstetrics, Gynecology and
Reproductive Health Services, and Director, Philip R. Lee Institute for
Health Policy Studies, School of Medicine, University of California,
San Francisco
Angela Diaz, Jean C. and James W. Crystal Professor of Adolescent
Health, Department of Pediatrics and Community Preventative
Medicine, Mount Sinai Medical Center, New York, New York
Francisco Garcia, Distinguished Outreach Professor of Public Health,
Obstetrics and Gynecology; Director, University of Arizona Center
of Excellence in Women’s Health; and Codirector, Cancer Disparities
Institute, University of Arizona, Tucson
Kimberly Gregory, Vice Chair, Women’s Healthcare Quality and
Performance Improvement, Department of Obstetrics and
Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
Paula A. Johnson, Executive Director, Connors Center for Women’s
Health and Gender Biology, and Chief, Division of Women’s Health,
Brigham and Women’s Hospital, Boston, Massachusetts
Anthony Lo Sasso, Professor and Senior Research Scientist, Division of
Health Policy and Administration, University of Illinois at Chicago
School of Public Health
Jeanette H. Magnus, Cecile Usdin Professor in Women’s Health and
Chair, Department of Community Health Sciences, School of Public
Health and Tropical Medicine, Tulane University, New Orleans,
Louisiana
Heidi D. Nelson, Research Professor of Medical Informatics and Clinical
Epidemiology and Medicine, Oregon Health and Science University,
and Medical Director for Cancer Prevention and Screening,
Providence Cancer Center, Providence Health & Services, Portland,
Oregon
Roberta B. Ness, Dean and M. David Low Chair in Public Health, School
of Public Health, University of Texas, Houston
Magda G. Peck, Professor of Public Health and Pediatrics and Associate
Dean for Community Engagement and Public Health Practice,
College of Public Health, University of Nebraska Medical Centers,
Omaha, Nebraska
v
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E. Albert Reece, Vice President for Medical Affairs, University of
Maryland, and John Z. and Akiko K. Bowers Distinguished Professor
and Dean, University of Maryland School of Medicine, Baltimore
Alina Salganicoff, Vice President and Director, Women’s Health Policy,
Henry J. Kaiser Family Foundation, Menlo Park, California
Sally W. Vernon, Division Director, Health Promotion and Behavioral
Sciences, Blair Justice, Ph.D. Professorship in Mind-Body Medicine
and Public Health, and Professor of Epidemiology and Behavioral
Sciences, University of Texas School of Public Health, Houston
Carol S. Weisman, Distinguished Professor of Public Health Sciences and
Obstetrics and Gynecology and Associate Dean for Faculty Affairs,
Pennsylvania State University College of Medicine, Hershey
Study Staff
Karen Helsing, Study Director
Jesse Flynn, Associate Program Officer
Suzanne Landi, Research Assistant
Chelsea Frakes, Senior Program Assistant
Rebekah E. Gee, Institute of Medicine Anniversary Fellow
Amy Pryzbocki, Financial Associate
Rose Marie Martinez, Senior Director, Board on Population Health and
Public Health Practice
vi
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Reviewers
This report has been reviewed in draft form by persons chosen for their
diverse perspectives and technical expertise in accordance with procedures
approved by the National Research Council’s Report Review Committee.
The purpose of this independent review is to provide candid and critical
comments that will assist the institution in making its published report as
sound as possible and to ensure that the report meets institutional standards
of objectivity, evidence, and responsiveness to the study charge. The review
comments and draft manuscript remain confidential to protect the integrity
of the deliberative process. We thank the following for their review of this
report:
Eli Y. Adashi, Professor of Medical Science, The Warren Alpert
Medical School, Brown University
Wylie Burke, Professor and Chair, Department of Bioethics and
Humanities, School of Medicine, University of Washington
Ned Calonge, President and Chief Executive Officer, The Colorado
Trust
Carol A. Ford, Chief, Craig Dalsimer Division of Adolescent
Medicine and Orton Jackson Endowed Chair in Adolescent
Medicine, the Children’s Hospital of Philadelphia
Paula M. Lantz, S.J. Axelrod Collegiate Professor of Health
Management and Policy and Chair, Department of Health
Management and Policy, School of Public Health, University of
Michigan
JoAnn E. Manson, Chief, Division of Preventive Medicine, Brigham
and Women’s Hospital and Elizabeth F. Brigham Professor of
Medicine and Women’s Health, Harvard Medical School
vii
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viii REVIEWERS
Gary E. Raskob, Dean and Professor of Epidemiology and Medicine,
College of Public Health, University of Oklahoma Health
Sciences Center
Rita Redberg, Director, Women’s Cardiovascular Services Medical
Center, University of California, San Francisco
Sara Rosenbaum, Hirsh Professor and Chair, Department of Health
Policy, School of Public Health and Health Services, The George
Washington University Medical Center
Donna Strobino, Professor and Vice Chair of Education, Bloomberg
School of Public Health, Johns Hopkins University
Nancy Fugate Woods, Dean Emeritus, School of Nursing, University
of Washington
Although the reviewers listed above have provided many constructive
comments and suggestions, they were not asked to endorse the conclusions
or recommendations, nor did they see the final draft of the report before its
release. The review of the report was overseen by Nancy E. Adler, Profes-
sor of Medical Psychology, Departments of Psychiatry and Pediatrics, and
Director, Center for Health and Community, University of California, San
Francisco and Susan J. Curry, Dean, College of Public Health, University
of Iowa. Appointed by the National Research Council and Institute of
Medicine, they were responsible for making certain that an independent
examination of the report was carried out in accordance with institutional
procedures and that all review comments were carefully considered. Re-
sponsibility for the final content of the report rests entirely with the author
committee and the institution.
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Preface
As chair of the Committee on Preventive Services for Women, I want
to personally thank my fellow committee members for their willingness to
serve, for their hard work, and for contributing their remarkable expertise
to this study. I have been honored to contribute to this effort. Each of
us works in different domains relating to preventive health services, and
although the short time frame provided to perform this study presented a
challenge, my esteemed colleagues who comprised the committee worked
as a team with great dedication and spirit to achieve consensus. It was a
pleasure to work with each and every one of them.
The diverse committee involves an impressive array of researchers and
practitioners, including two members who served on the United States Pre-
ventive Services Task Force (USPSTF) and one who leads USPSTF systematic
evidence reviews. Although we could not conduct a USPSTF-style system-
atic review for any single preventable health condition or determinant of
well-being, nor were we expected to do so, I believe that our end product is
a study that has important, evidence-based recommendations that provide
a road map to improved preventive services for women. Throughout the
process we repeatedly asked ourselves whether the disease or condition that
we were addressing was of significance to women and especially whether
it was more common or more serious in women than in men or whether
women experienced different outcomes or benefited from different interven-
tions than men. I believe that the preventive services that we recommend
for consideration in this report readily satisfy these questions.
The Patient Protection and Affordable Care Act of 2010 has afforded
ix
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x PREFACE
us an historic occasion. For the first time, prevention plays a central role
within the scope of new health insurance plans in the United States. Also,
an ongoing focus on women’s preventive services is expected to be included
in these efforts. Given the history of inadequate attention to women’s health
research and preventive services noted by many (including previous Institute
of Medicine [IOM] committees), I am truly optimistic that gains in women’s
health and well-being will ensue. With the multiple roles that women play
in society, to invest in the health and well-being of women is to invest in
progress for all.
I regret that we were unable to resolve to his satisfaction the issues
raised by one committee member, Anthony Lo Sasso. In his statement of
dissent, he identifies his main concerns, which are with the constraints of
the study’s charge and subsequent process. His statement, along with the
committee’s response, can be found in Appendix D of the report.
I thank the IOM staff, especially our senior project officer, Karen
Helsing, and also Jesse Flynn, Suzanne Landi, Chelsea Frakes, and IOM
Anniversary Fellow Rebekah Gee. All went above and beyond to support
the committee throughout the process. We also are indebted to Rose Marie
Martinez, senior director of the Board on Population Health and Public
Health Practice, for her presence throughout and her invaluable guidance
and support. I am grateful as well to those who presented and attended
our committee’s open sessions and those who submitted comments and
informed our work with their research and opinion pieces. Without their
dedicated work this report would not have been possible.
Linda Rosenstock, Chair
Committee on Preventive Services for Women
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Contents
SUMMARY 1
1 INTRODUCTION 15
Specifics of the Legislation, 15
Role of Prevention in Addressing Health and Well-Being, 16
Why Women?, 18
Preventive Services for Women, 20
Committee on Preventive Services for Women, 20
Committee Process, 22
References, 26
2 PREVENTIVE SERVICES DEFINED BY THE ACA 29
United States Preventive Services Task Force, 29
Bright Futures—American Academy of Pediatrics, 37
Advisory Committee on Immunization Practices, 43
References, 46
3 EXISTING COVERAGE PRACTICES OF NATIONAL,
STATE, AND PRIVATE HEALTH PLANS 47
Rules Governing Coverage Requirements Before and
After the ACA, 48
Discussion, 64
References, 64
xi
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xii CONTENTS
4 COMMITTEE METHODOLOGY 67
Review of USPSTF Recommendations, 67
Review of Bright Futures Recommendations, 72
Review of ACIP Recommendations, 73
Further Committee Considerations, 73
Recommendations on Preventive Services to Be Considered in
Development of Comprehensive Guidelines, 77
References, 77
5 RECOMMENDATIONS 79
Diabetes and Gestational Diabetes, 79
Cervical Cancer, 88
Sexually Transmitted Infections, 94
Human Immunodeficiency Virus Infection, 98
Preventing Unintended Pregnancy and Promoting
Healthy Birth Spacing, 102
Breastfeeding, 110
Interpersonal and Domestic Violence, 117
Well-Woman Preventive Visits, 123
References, 135
6 PROCESS FOR REGULARLY UPDATING THE
RECOMMENDATIONS 157
Guiding Principles and Recommendations, 158
A Preventive Services Coverage Commission, 158
Role of Evidence-Based Review Bodies, 159
Discussion, 160
References, 162
7 FINDINGS AND RECOMMENDATIONS FOR
ADDRESSING IDENTIFIED GAPS IN PREVENTIVE
SERVICES FOR WOMEN 163
Concluding Observations from the Committee, 163
References, 168
APPENDIXES
A CLARIFICATIONS 171
Cardiovascular Disease, 171
Bone/Skeletal Disease, 178
Breast Cancer, 182
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xiii
CONTENTS
Mental Health, 188
Tobacco Use, 193
Diet/Physical Activity, 198
References, 202
B AGENDAS OF PUBLIC MEETINGS HELD BY THE
COMMITTEE ON PREVENTIVE SERVICES FOR WOMEN 217
C COMMITTEE BIOGRAPHIES 223
D DISSENT AND RESPONSE 231
