Data LookBook Vol. 2 by metriarch

data lookbook Vol. 2

Lookbook Vol. 2

With special thanks to:

Lookbook Vol. 2

METRIARCH MEMBERS

Tulsa

CONTENTS A B O U T MET R I AR C H

H I GH L I G H T ED FAC T S

M E SS AG E F R O M MO NICA M US G RAV E

I N T RO D U C T I O N 4 P URP O S E 5 P RO CES S 6 D O M AI N 1 - Ac c e ss to Qual ity Care Adequate Prenatal Care...................................10 Access to Mental Health Services..............11

D O M AI N 2 - Ad o l e sc e n t Health

D O M AI N 3 - Ec o n o m i c Fac to r s

D O M AI N 4 - Ed u c a ti o n

Teen Birth Control Usage...............................20 Teen Sexual Activity............................................ 21 Drug or Alcohol ...of Teens......................... ...22 Teen Condom Usage..................................... .....23 Teen Birth Rate..................................................... 24 Women Experiencing Poverty..................... 28 Food Insecurity...................................................... 29 Single Parent Head of Households...........30 Gender Pay Gap.................................................... 31 Cost of Child Care.............................................. 32 Substandard Housing......................................... 33 Female SNAP Recipients...............................34

High School Drop-Out Rate........................ 38 Women with a College Degree................... 39 Subsequent Teen Births.................................. 40 High School Graduation Rates.....................41

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Uninsured Women............................................... 12 Unable to See Doctor Due to Cost........... 13 Access to Dental Care.......................................14 Consistent Primary Care................................. 15 Baby-Friendly Hospitals................................... 16

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CONTENTS D O M AI N 5 - Fo u n d a ti o nal Health

D O M AI N 6 - Ma te r n a l a n d Chil d Health

Women Who Smoke..........................................44 Poor Health Perceptions............................... ..45 Physical Inactivity................................................46 Obesity....................................................................... 47

Preterm Births.......................................................50 Low Birthweight..................................................... 51 Tobacco Use in Pregnancy.......................... ...52 Healthy Birth Spacing................................... ....53 Maternal Mortality..............................................54 Neonatal Death.................................................... 55 Exclusive Breastfeeding................................... 56

D O M AI N 7 - Me n ta l He al th

D O M AI N 8 - S o c i a l D y n amic s

Binge Drinking.......................................................60 Postpartum Depression.................................... 61 Drug-Related Deaths........................................ 62 Frequent Mental Distress............................... 63 Depression................................................................64 Sexual Violence.....................................................68 Female Incarceration......................................... 69 ACEs Reported..................................................... 70 Intimate Partner Violence............................... 71 Political Representation................................... 72 Amenities.................................................................. 73

RE F E R ENC ES 74 AC KN OWL ED G MENT S 8 0

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MISSIO N Metriarch is a statewide data collaborative that aims to normalize and broaden women’s health conversations in Oklahoma through data storytelling, resource curation, and interactive outreach events.

VISION

Metriarch envisions an Oklahoma where: • Everyone recognizes advancing women’s health is essential to the advancement of all public health and economic outcomes • Women’s health conversations are centered around human dignity, inherent value and essential security for women and their families • Everyone has equitable access to publicly available health data and sees themselves reflected in the data that is collected • Individuals and organizations utilize various women’s health indicators and data-sets to evaluate, strategize and act to promote women’s health

OPEN I N V I TE : A LL AR E WE LCO M E Metriarch invites any individual or organization committed to nuanced, evidencebased and medically accurate dialogue and information regarding women’s health and well-being to join our collaborative. p. 1

For more information visit MetriarchOK.org.

FOOD INSECURITY

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QUICK FACTS

Oklahoma women are the fifth most food insecure nationwide. PRETERM BIRTH T E E N B I R T H R AT E

Between 2009 and 2019 the teen birth rate decreased by 52.2 percent, falling from 57.4 to 27.4 births per every thousand women.

M E N TA L D I S T R E S S

One in five Oklahoma women report frequent mental distress.

SEXUAL VIOLENCE

V O T E R PA R T I C I PAT I O N

Increased female voter turnout in the 2018 midterm elections mirrored the nation at 12 percent.

CHILDHOOD TRAUMA

Oklahoma has high rates of intimate partner violence, and has the highest rate of women reporting an incidence of contact rape in their lifetime.

L ACK OF INSURANCE

Oklahoma has the sixthhighest rate for Adverse Childhood Experiences (ACEs) in the nation.

BINGE DRINKING

05 19 percent of Oklahoma women go without insurance, making Oklahoma secondto-last ranked in insurance coverage for women.

Preterm birth remains high in Oklahoma, the sixth-worst in the nation.

Binge drinking is comparatively low in Oklahoma, ranking 5 out of 51.

F E M A L E I N C A R C E R AT I O N

Oklahoma incarcerates the second-highest number of women in the nation.

TOBACCO USE IN PREGNANCY

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In the past four years, tobacco use during pregnancy decreased nearly 17 percent from 13.1 percent to 10.9 percent of women giving birth.

P O L I T I C A L R E P R E S E N TAT I O N

As of 2020, 21.5 percent of our state legislators are women, a 60 percent increase in participation from 2018.

This past year, a real buzzword we heard flying around was ‘accountability’. With the COVID-19 pandemic, the surge in the Black Lives Matter movement, and 2020 being a major election year, there were so many pushes from every direction to be accountable: we were accountable to each other when it came to trying to control the spread of disease, we needed our police departments to be held accountable for their brutality, we wanted our politicians to detail how they’d remain accountable to their constituents. Accountability ensures a level of trust and responsibility between groups with the end goal of progress in mind; a tomorrow that’s better than today. That’s what Metriarch is all about.

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A ME SSAGE F R O M T U L S A S C H O O L TE ACH ER, M O N I C A M U S GR AV E

By collecting this data, we took the first step in holding Oklahoma accountable for the health and wellbeing of half of its population. We named that just looking at “the lower half of the human anatomy” when considering women’s health was short-sighted, and that we needed to think outside of the box if we were going to make a difference in the field. That, outside of the confines of the box that we often put women’s health inside, there are actually many domains that affect women’s health, and our understanding of these domains -- both where we currently stand and where we need to go -- are crucial to progress. By publishing this data, we called others to join us in holding our state accountable for the inequities the women of our state suffer. We put the current state of women’s health on display for all to see, in clear language so that no one can claim ignorance to the issue: women’s health is a human rights issue that affects all of us. By continually updating this data, we’re letting everyone know that women’s health still matters, and that we’re all still accountable. We’re acknowledging that these aren’t small blemishes on our state’s report card, things that can be easily fixed and then brushed aside; they’re still issues. Nearly 20% of all women in our state are uninsured. We ranked 48th in teen birth, 44th in preterm births, and 45th for frequent mental distress. We have the highest rate of sexual violence in the country, consistently rank in the bottom 25% for maternal health, and rates of women using tobacco while pregnant in Oklahoma is nearly double the national average. And these issues will continue to remain as such unless we continually hold ourselves accountable to make it better. Sincerely,

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Monica Musgrave

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I N T R O DU C T I O N Contrary to what many believe, women’s health is not relegated to the lower half of the human anatomy, and it doesn’t begin and end in a doctor’s office. In reality, it is a broad topic encompassing both quantitative and qualitative factors intersecting with an array of societal issues. This Data Lookbook highlights eight key areas providing a comprehensive perspective on the status of the health and well-being of Oklahoma women. These perspectives are intended to support dialog and generate better conversations around the complex nature of women’s health. The eight key areas include: Access to Quality Care, Adolescent Health, Economic Factors, Education, Health Foundations, Maternal and Child Health, Mental Health, and Social Dynamics. When compared to the majority of other states, Oklahoma has failed in providing women with adequate and equal economic opportunities, access to care, and safety net supports they need to thrive. On the way to becoming a “top 10 state,” it must be a priority to address these inequities adversely affecting half of the state’s population. Specifically, we must better support women of color in Oklahoma, who are most likely to bear the brunt of inequity, and have experienced marginalization throughout the course of Oklahoma’s history. In today’s Oklahoma, Indigenous women are still experiencing the detrimental effects of colonization, Black women in Tulsa still labor to repair the economic devastation inflicted by the 1921 Race Massacre, and one in every four Latinx women lives in poverty. The consequences of this institutionalized inequities are felt across our state and seen within our health outcomes. Despite these harsh realities, Oklahoma is undergoing momentous change. Thanks to the dedication and good work of public servants across the state, we have continued to see a decline in teen birth rates, and have made the Top 10 List as a leading state in providing access to the most effective forms of birth control.1 Our state legislature has more female representation than ever before. Overall smoking rates3,4 and excessive drinking rates have declined.2 Oklahoma is progressing, and the women of our state will be better for it. This Data Lookbook is your social-change toolkit. The data sets within these pages easily inform on several areas that are relevant to the health and well-being of the women of our state. These data

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belong to the public so feel free to share this broadly with friends, family, community leaders and elected officials. Consider this Lookbook your concisely designed Swiss Army Knife of data, helping you cut through the needless taboo associated with women’s health as you promote change across Oklahoma.

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PURPOSE Have you ever gotten your hands on a community index or report and felt completely overwhelmed by the contents inside? Or perhaps you have worked on a team creating such a report, then realized halfway through that the technicality of your methods created barriers that potentially alienated a broad segment of your intended audience? The Metriarch collaborative experienced both predicaments and chose to respond by creating resources that strive to break down communication barriers in order to better democratize data. This Data Lookbook is not an academic instrument; it is a collection of curated data commonly referenced in discussions about women’s health and well-being. Oklahoma is fortunate to have a respectable body of data practitioners and researchers who have made it their life’s work to collect, analyze, and interpret data for public use. This Lookbook is a supplement, not a substitute, to the indepth research and reporting generated by scholars and government entities. In response to the need for accurate, comprehensive, and easy to understand information about the status of health and well-being of Oklahoma women we created this Data Lookbook. The methods used to identify, validate, and organize these data have been conducted and overseen by experts in their fields, as well as experts in their own lived-experiences, and is designed to be accessible and straightforward to read.

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Every Oklahoman has the right to access and understand the statistical realities of what it means to be a woman in our state. To better explain how women in Oklahoma are faring compared to women in the rest of the country, this Data Lookbook examines eight key areas and a total of forty-three indicators, related to women’s health to provide a broad overview of the status of Oklahoma women. The eight key areas include: Access to Quality Care, Adolescent Health, Economic Factors, Education, Foundational Health, Maternal and Child Health, Mental Health and Social Dynamics, and were selected because, there is not one, but many factors comprising women’s health and well-being.

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PR O C E S S Each indicator page will include the title of the indicator, an explanation of what it means, as well as a mini literature review providing necessary context for the topic. National averages or rates will be compared with those of Oklahoma, and proxies will be defined and used in instances where those data are not available. Affording dignity to others is acknowledging the full intersection of their identities, and that is not possible to do with data if aspects of their identity are unaccounted for. The Lookbook will reference and reinforce social and institutional determinants of health that may not be included as part of national surveys and data collection efforts. To provide perspective on identities that are often made invisible by this exclusion, this Lookbook includes supporting data that document: violence against Indigenous women, individual stories of Black mothers interacting with the health care system, and how gender identity and sexual orientation affect outcomes, among other topics. Data equity is as much an ethical concern as it is an empirical one, as our values are reflected in the things we measure. Throughout this Lookbook, most notably in the narrative sections for each indicator, evidence from reputable organizations and academic literature are used to address the limitations of mainstream data collection. This is essential to creating a Data Lookbook that incorporates the lived experiences of all Oklahoma women, not simply those who are the easiest to measure. Between the first and second volume of the Lookbook, several edits were made. These include adding indicators related to breastfeeding and baby-friendly hospitals. We also updated each indicator with

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the most recent, publicly available information, and refined the appropriateness of the indicators selected. With this last point in mind, the indicator for post-secondary education was changed from “Women with the Bachelor’s Degree,” to “Women with a College Degree.” This was done to acknowledge the achievement of all of those who have pursued higher education, and provide a more accurate picture of college level degree attainment. The last notable change was for “Teen Birth Rate.” In this edition of the Lookbook, it is the only instance where multiple data sources are cited within the definition, as preliminary data were used from both state and national sources.

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Metriarch’s Data Lookbook is an intentionally evolving document, where new insights are welcomed with each year’s edition. The changes made this year were crowdsourced across the Metriarch Collaborative and beyond. If you or your organization would like to get engaged in the Lookbook process, we welcome your collaboration. It requires a range of perspectives and actions to advance the overall health of Oklahoma women, and we pledge to keep the process of interpreting data used to achieve these aims equally dynamic and inclusive.

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Access to Quality Care Women often encounter issues affording medical care, and those who can are not always able to have beneficial discussions regarding their feelings of stress, anxiety, or depression. The cost of seeing a doctor is the most common reason Oklahoma women go without health care.5 Finally, in 2020 Medicaid expansion was approved in Oklahoma by referendum, which in many ways improves our outlook for the future of women’s health with in our state. As we look at the realities of where we stand today, however, women between the ages of 18-64 lack consistent or fiscally attainable health care coverage. For many women in Oklahoma inconsistent or inadequate health care coverage results in poorly managed chronic health conditions. 5 Available coverage options are not the only issues plaguing women in Oklahoma, with urban and rural health care delivery systems continue to struggle, with many failing and closing. Rural clinic and hospital closures have required Oklahoma women to travel distances greater than 30 minutes for primary care and often much longer than 60 minutes for specialized care. 6 These barriers significantly impact women’s ability to afford and access basic, primary care, and further complicate women’s ability to receive comprehensive prenatal care.7 Despite having 411.3 mental health providers per every 100,000 residents, this rate is misleading, and does not explain significant gaps in services felt across the state.7 The complexities of health coverage, the lack of available localized services, and limited resources continue to hinder the ability for the women of Oklahoma to improve their health. The women of Oklahoma deserve better.

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DEFINITION

The number of psychiatrists, psychologists, licensed clinical social workers, counselors, marriage and family therapists, providers that treat alcohol and other drug abuse, and advanced practice nurses specializing in mental health care per 100,000 population in 2020. 7

OKLAHOMA 411.3 per 100,000 residents

NATIONAL AVERAGE 268.6 per 100,000 residents

Access to Mental Health Services Data Highlight: Oklahoma ranks 9 (of 50) for the number of providers, though experts warn this number is misleading.7,11 Massachusetts has the most mental health providers with a rate of 666.4, while Alabama has the smallest number with a rate of 112.7 per 100,000 residents.7

Why We Care: “I started calling a list of psychiatrists who supposedly took my insurance. Some of them were dead. Many weren’t taking new patients. Others didn’t take my insurance.” 12 This first-person account describes a common interaction with “Ghost Networks” in Psychiatry, and in part explains why Oklahoma appears to have a large network of mental health providers (411.3 per every 100,000 residents), but significant gaps in coverage remain. Additionally, because reported provider rates are inclusive of those clinicians who are no longer practicing, as well as those who work in the private industry, the rates do not fully represent the landscape of accessible services in Oklahoma.11 Women are twice as likely as men to develop anxiety disorders, the most common group of mental health disorders in the United States. Though women are more likely than men to access care, there is still a substantial societal stigma around mental illness dissuading many women from receiving the critical care they need. This is especially true in certain communities of color, and members of the LGBTQ+ community, where discussing mental illness is avoided as a protective measure to avoid further discrimination against themselves and their community. 13 For women without insurance, and those from low-income backgrounds, economic barriers to access persist. 5 What We Can Do: - Continue to support the safety net providers across the state through maintaining legislative allocations for social service organizations providing mental health services - Support the identification and deployment of diverse mental health providers representative of the populations being served within our communities p. 10

Data Highlight: Oklahoma ranks 29 (of 51) for adequate prenatal care. Vermont leads the nation with 90.9 percent of women receiving adequate prenatal care; in comparison, only 64.6 percent of women in New Mexico will receive adequate prenatal care. 8

DEFINITION

The percent of women who received adequate prenatal care, which is defined as care than begins in the 1st trimester, and includes 10 or more visits in 2018.8

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Adequate Prenatal Care

OKLAHOMA 76.5 percent

NATIONAL AVERAGE 76.4 percent

Why We Care: Adequate access to prenatal care is vital to the health and well-being of the mother and baby during pregnancy. Regular doctor visits allow moms to address health concerns throughout the pregnancy, such as weight gain during pregnancy, which increases the likelihood the baby is born full term and at a healthy weight. Adequate weight gain is an important part of physical and cognitive development for the baby.9 It not only lessens the likelihood that an infant will require emergency care once born, but increases the chances that an infant will survive its first year. Improved infant outcomes help reduce maternal stress, while lessening the likelihood maternal mental health conditions will develop. It matters that women have consistent access to health care. Women who begin their pregnancies in good health are less likely to experience birth complications, making access to health care before pregnancy a critical piece of women’s and children’s health care. 10

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What We Can Do: - More intentionally publicize and support the enrollment processes for private, Tribal, and public (SoonerCare, Insure Oklahoma) insurers along with other localized resources providing pathways for early entry into prenatal care - Support organizations engaged in the implementation of Medicaid expansion

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DEFINITION

The percent of women who report being unable to see a doctor due to cost reported in 2019. 19

OKLAHOMA 18.3 percent

NATIONAL AVERAGE 14.6 percent

Unable to See Doctor Due to Cost Data Highlight: As of 2017, 30 percent of Oklahomans reported having unpaid medical debt, the eighth-most indebted state in the nation. 20

Why We Care: Many Oklahoma women are uninsured or underinsured and unable to afford regular medical care. Presently, very defined groups of women have access to Oklahoma’s Medicaid (SoonerCare), insurance Marketplace vouchers, and a small number of free clinics in urban areas. While some women who meet income requirements can access these services, there is excessive red tape making it difficult for all women to access that care. Further complicating matters, rural Oklahoma clinics and hospitals have closed en masse, making the already burdensome cost of seeking medical care more burdensome due to increased transportation requirements.21 In addition to affordability, women often lack time and flexibility to access a consistent provider. When surveyed, 24 percent of women said that they didn’t see a doctor because they couldn’t find the time, and for low-income women this number rose to 34 percent.22 What We Can Do: - Support organizations engaged in the implementation of Medicaid expansion - Explore innovative primary care practices such as Telemedicine

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DEFINITION

The percent of uninsured women ages 19-64 reported in 2018-2019.14

OKLAHOMA Data Highlight: Leading the nation, only 2.7 percent of women in Washington D.C. are uninsured. Oklahoma ranks 50 (of 51) for the overall percentage of uninsured women, only beating out Texas, with 23.3 percent of women uninsured.14

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Uninsured Women

19 percent

NATIONAL AVERAGE 11.4 percent

Why We Care: From an economic perspective, expanded access to insurance makes perfect sense as it costs less to prevent illness than it does to treat it.15 Our nation spends $3.3 trillion annually on our health care budget, 90 percent of that sum goes towards treating chronic and mental health conditions.16 Despite how much women accomplish in the face of adversity, they are not superheroes. Women are twice as likely as men to be diagnosed with an anxiety disorder. 17 Women must also receive a high standard of care before a pregnancy, during delivery, and after she has given birth in order to ensure the long-term health of mom and baby. Finally, women are often the caretakers of children and other family members, and are at risk of chronic fatigue and burnout at rates much higher than those of men. As new research comes forward linking toxic stress to the development of mental illness and other chronic conditions, it becomes increasingly essential for women to have access to quality care.18

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What We Can Do: - Restore dignity to the health care debate by recognizing that adequate health care is a fundamental human right - Support organizations engaged in the implementation of Medicaid expansion

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DEFINITION

As of 2018, the percentage of women ages 18-44 who reported having one or more people they think of as their personal doctor or health care provider.26

OKLAHOMA 70 percent

NATIONAL AVERAGE 71.8 percent

Consistent Primary Care Data Highlight: Oklahoma ranks 36 (of 50) for the provision of consistent primary health care.26

Why We Care: There are few relationships requiring such a high level of trust and transparency as that between a patient and their physician. For women, consistent primary care is especially crucial as studies show women with this care between the ages of 20-64 are four times more likely to miss screenings for breast and cervical cancer than their peers with primary care. 26 Positive, consistent health care interactions are especially important for younger women who are more likely to become pregnant as it helps those women begin pregnancy healthier due to their regularly attending check-ups. 26 Latinx women tend to see a regular doctor less than their Black or White peers. Low-income women are also less likely to have a regular physician. As the field of medicine is dominated by White, affluent men and women, diversifying the clinician base to include those representative of the communities they serve could increase trust and improve health care interactions with women of color and other marginalized women.26 What We Can Do: - Ensure community clinics in underserved communities are well-staffed and able to facilitate positive, culturally-competent, long-lasting relationships with their patients through culturally informed practices - Expand access to affordable, high-quality insurance in order for women to access primary care for prevention services more readily - Provide more dynamic pathways from medical school entrance to foster more biographically representative physicians - Ensure that mid-level providers are permitted to practice within the full scope of their license

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Data Highlight: Oklahoma ranks 43 (of 51), for women accessing dental services. Connecticut currently provides the best access to dental services for women with 80 percent reporting a dental visit within the past year. Only 57.8 percent of Louisiana women report dental visits within the past year.23

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Access to Dental Care

DEFINITION

As of 2018, the percentage of women ages 18-44 who reported visiting the dentist or dental clinic within the past year.23

OKLAHOMA 61.8 percent

NATIONAL AVERAGE 68.4 percent

Why We Care: While it is important for everyone to go to the dentist at least twice a year, access to dental services is especially essential for women. Dental issues can sometimes arise from benign hormone changes in the body during menstrual cycles, pregnancy, and menopause.24 While dental hygiene might seem like a lower priority when considering other health-related needs, gum disease is strongly correlated with heart disease and diabetes, and excessive tooth loss is connected to coronary artery disease.24 These issues are exacerbated during pregnancy when women are more likely to experience gum disease.24 Furthermore, from an economic perspective, poor dental hygiene and tooth loss affect hiring and job promotion. 25

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What We Can Do: - Encourage lawmakers to include provisions for dental care access in state sponsored health programs - Support comprehensive Medicaid Expansion initiatives - Encourage local employers to include preventative dental coverage in their insurance benefit plans - Provide more dynamic pathways from medical school entrance to foster more biographically representative physicians

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DEFINITION

As of 2020, the percentage of hospitals that are designated “baby-friendly,” a World Health Organization quality standard 123 .

OKLAHOMA 31.7 percent

NATIONAL AVERAGE 28.5 percent

Baby-Friendly Hospitals Data Highlight: 32 percent of all births in Oklahoma are at BFHI facilities. BFHI hospitals have higher rates of breastfeeding amongst children born at designated facilities compared to facilities without the accreditation.123

Why We Care: Baby-Friendly Hospital Initiative (BFHI) designated hospitals have adopted procedures that emphasize breastfeeding importance in their practices. Breastfeeding is the optimal way to provide nourishment and promote health for mother and child. 123 Studies show that babies exclusively breastfed for the first six months of their lives are at a lower risk of illnesses like diabetes, childhood cancers, and sudden infant death syndrome (SIDS). 124,125 Begun in 1991 by the WHO and UNICEF, the BFHI stands on three basic pillars that outline the importance of human breast milk, mother-child bonding, and education about breastfeeding. Education is a cornerstone of BFHI accreditation, although providing evidence-based breastfeeding care is also required. 124 In addition, racial and ethnic inequities are decreased in BFHI hospitals. Oklahoma currently has ten BFHI certified hospitals across the state, with three more on track. 123 As a result, 32 percent of all births in Oklahoma are at BFHI facilities. BFHI hospitals have higher rates of breastfeeding amongst children born at designated facilities compared to facilities without the accreditation. 123 The importance of breastfeeding cannot be overstated and this is why it is important that Oklahoma prioritize breastfeeding: It impacts the wellbeing of Oklahoma families. What We Can Do: - Encourage hospitals to become Baby-Friendly Hospital Initiative facilities - Allocate resources for hospitals to become BFHI certified

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Adolescent Health Adolescence can be a challenging time. It’s a critical juncture between childhood and adulthood when we grapple with who we are and start to develop an understanding of who we want to become. It’s a time filled with glorious trial and error. Most of us pass through this awkward stage of life with doubts and insecurities. It is critical to remember this reality when we look at the lives of others, and evaluate the decisions that young people make that are likely to lead toward unfavorable health outcomes later. Specifically, behaviors like engaging in unprotected sex, drugs/ alcohol use, and other risky behaviors can result in STIs, unintended pregnancy, and sometimes trauma.27 Young women are often more vulnerable to adverse outcomes associated with these behaviors, and require intentional support to thrive during this often challenging part of life. Fortunately, Oklahoma has seen a decrease in teen pregnancy over the past decade, and as a cohort, teens have become much savvier about safer sex practices, and are more aware of what defines a healthy relationship. While this is great progress, there is still work to be done. It is society’s job to support teens in their decision-making that build upon their inherent self-worth and authentic confidence.

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DEFINITION

The percent of sexually active teen females that did not use birth control pills, an intrauterine device or arm implant, an injectable shot, patch or birth control ring before last sexual intercourse reported in 2019.30

Teen Birth Control Usage

OKLAHOMA

Data Highlight: Beyond condoms, female teens using birth control are more NATIONAL AVERAGE likely to choose highly effective forms of birth control, such 64.8 percent as the intrauterine device (IUD) and the arm implant, with 72 percent selecting these methods over other options nationwide. 31 62.3 percent

Why We Care: Access to any form of birth control can lower the incidence of unintended pregnancy and allow women to practice healthy birth-spacing.31 When women have access to a full range of contraceptive methods they are able to make the most informed decision on what method works the best for them.31 The most effective forms of birth control, the Intrauterine Device (IUD) and the arm implant, have increased in popularity in recent years with 72 percent of teens nationwide choosing one of these methods as their preferred birth control.31 The recent adoption of these highly effective methods and the overall reduction in teen sexual activity is associated with decreasing teen pregnancy rates.31 What We Can Do: - Ensure individuals have adequate information and access to all forms of birth control in order to choose the best method for their lifestyle - Support inclusive, scientific, evidence-based prevention programming addressing subsequent teen births - Advocate for comprehensive, inclusive, scientific, and evidence-based health education in all Oklahoma schools

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DEFINITION

The percent of female high school students who reported to be sexually active when surveyed in 2019. 28

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Teen Sexual Activity

OKLAHOMA 29.7 percent Data Highlight: The percent of teens postponing sexual activity is increasing NATIONAL AVERAGE across the country, and researchers have yet to pinpoint exactly 28.4 percent what is causing this change. Many are studying how cultural changes caused by the internet might have caused this and other behavioral shifts. 29 Why We Care: Nationwide, the percentage of teens engaging in sexual activity is declining. 28 While experts are still unsure why this is, they are certain abstinence-based programming and fear-promoting tactics do little to dissuade sexual activity.29 It is thought the internet may deserve some credit for a reduction in several high-risk behaviors among teens, simply because they are far more engaged in virtual life than former generations.29 Most teens have at least one social media account, with 71 percent reporting use of at least two regularly, and this social shift is linked to postponing sexual activity.29 The flip side of this benefit is that teens are also influenced by unrealistic representations of sex found on the internet, often distorting their understanding of what real human sexual relationships entail.29 While delayed sexual activity is associated with positive health outcomes in general, misinformation found online about sex could be harmful to teens if not countered by comprehensive sex education.29

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What We Can Do: - Ensure individuals have adequate information and access to all forms of birth control in order to choose the best method for their lifestyle - Support inclusive, scientific, evidence-based prevention programming addressing subsequent teen births - Advocate for comprehensive, inclusive, scientific, and evidence-based health education in all Oklahoma schools.

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DEFINITION

The percent of sexually active females who drank alcohol or used drugs before last sexual intercourse reported in 2019.34

OKLAHOMA

Drug or Alcohol Facilitated Sex of Teens

16.8 percent

Data Highlight: In 2016, House Bill 2398 passed the Oklahoma State Legislature. 18.6 percent This bill better defined that necessary consent for a sexual act requires affirmative, unambiguous and voluntary consent that may not be possible to obtain when a person is under the influence of drugs or alcohol. 35 As of January 2021, consent education is not mandatory in Oklahoma public schools. NATIONAL AVERAGE

Why We Care: The use of drugs and alcohol before sexual activity often results in unsafe sex practices, where individuals are less likely to use condoms or other protections to prevent unintended pregnancy. 27 Individuals who are under the influence of drugs or alcohol are not always able to make fully lucid decisions and are often too intoxicated to affirmatively, unambiguously and voluntarily consent to sex.35 For this reason, drug or alcohol facilitated sex can increase the risk of unwanted sexual contact for all individuals. Women from all identities and backgrounds are more likely to experience unwanted sexual contact than men, and low-income women are especially vulnerable. 27,35 What We Can Do: - Support existing evidence-based prevention programs which educate on consent, healthy relationship, and the effects of drugs and alcohol on decision making - Advocate for comprehensive, inclusive, scientific, and evidence-based health education in all Oklahoma schools, including consent curriculum - Restrain skepticism and judgment, as individuals, when others come forward with accounts of sexual harassment, assault, or rape

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DEFINITION

The percent of sexually active female high school students that reported they did not use a condom during their last sexual intercourse reported in 2019.32

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Teen Condom Usage

OKLAHOMA 49.2 percent Data Highlight: NATIONAL AVERAGE While condoms and contraceptives are widely used, “pulling50.4 percent out” is the second-most common form of contraception used by teens. This method is not highly effective with typical use, and is not widely accepted by Public Health experts as a contraceptive method altogether. 33 Why We Care: Among teens condoms are the most commonly used form of contraception. It is widely understood that condoms prevent unintended pregnancy, sexually transmitted infections (STIs), and with perfect use are 98 percent effective at preventing pregnancy. 33 Unfortunately, many teens do not know where they can easily access condoms or feel too self-conscious to purchase them in public.33 Barriers to accessing condoms can often lead to teens using the withdrawal method, which some experts do not consider an effective contraceptive method at all. The withdrawal method results in pregnancy 25 percent of the time with typical use and is used by 60 percent of sexually active teens.31

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What We Can Do: - Evaluate other data sources, in addition to the teen birth rates, to acknowledge the reproductive autonomy of teens and women overall - Support inclusive, scientific, evidence-based prevention programming addressing subsequent teen births - Advocate for comprehensive, inclusive, scientific, and evidence-based health education in all Oklahoma schools

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DEFINITION

For the year 2019, the number of births per 1,000 females ages 15-19.36

Teen Birth Rate

OKLAHOMA

Data Highlight: As of 2019, the Oklahoma teen birth rate has decreased 52.2 NATIONAL AVERAGE percent since 2009. In 2018, Oklahoma was ranked 46 in teen 16.6 per 1,000 births133 birth rate and was the fastest declining in the nation. 36 In 2019, however, the Oklahoma teen birth rate rose 1 percent, while the national average dropped 4.6 percent according to preliminary data.133 27.4 per 1,000 births36

Why We Care: The teen birth rate is often used as a proxy for unintended pregnancy though nearly 18 percent of teen pregnancies are intentional.37 The majority are not, and teen pregnancy can often thwart or abate educational and career goals of young parents. Teen birth rate has decreased by 52.2 percent in Oklahoma since 2009, a trend that mirrors reductions across the country, largely attributed to intentional, evidence-based and medically accurate prevention programming. 38 While this trend is promising, we find health inequities in the data, as Black and Latinx teens involved in the foster care system are twice as likely to experience a teen pregnancy. 39 What We Can Do: - Ensure individuals have adequate information and access to all forms of birth control in order to choose the best method for their lifestyle - Evaluate other data sources in addition to teen birth rates to acknowledge the reproductive autonomy of teens and women overall - Support inclusive, scientific, evidence-based, prevention programming addressing subsequent teen births - Advocate for comprehensive, inclusive, scientific, and evidence-based health education in all Oklahoma schools - Provide adequate support for expecting and parenting teens

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Economic Factors Many women in Oklahoma are leading households, while being paid less, with inadequate access to sick days, and without affordable childcare. Access to economic opportunities for women in Oklahoma can be limited especially depending on one’s geographic location, educational attainment, justice involvement, and health. There are also significant disparities in pay and job type due to race (women of color are disproportionately represented at higher rates in lower-paying, hourly work). 40 Consistent with the rest of the country, Oklahoma women still face discrimination in the workplace, part of the reason women make less than men on average. If equal pay were a reality in Oklahoma the overall poverty rate for working women in the state would be reduced by almost half and their total earnings would increase by about $5.4 billion a year collectively.46 Equal pay for equal work would not only close the gender wage gap but also allow Oklahoma’s women to better afford health care, housing, food, and a life above the poverty level. Perhaps the most direct and potentially effective measure we can take to create further pay transparency is to change workplace policies that reinforce secretkeeping about wages. Keeping this information private is generally of benefit to the employer often working against pay inequality. Addressing pay inequality and secrecy is a crucial part of closing the gender wage gap and protection from retaliation would be a very positive step forward for women’s economic security.

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DEFINITION

Pe r c e n t o f w o m e n a g e s 1 8 -5 4 below the poverty line ($12,760 for one person) for the year 2019. 42

OKLAHOMA

Women Experiencing Poverty

16.4 percent

Data Highlight: Oklahoma ranks 44 (of 51) in women living below the poverty 13.5 percent line. The best performing state is New Hampshire, with 8 percent, and the worst-performing state being Mississippi at 21.6 percent of its women living under the poverty line.42 NATIONAL AVERAGE

Why We Care: Sixteen percent of women in Oklahoma live below the poverty level compared to 15.8 percent of citizens overall. While this is a trend throughout the country more Oklahoma women are living below the poverty level compared to their peers across the U.S. When the demographics of women living below the poverty level are disaggregated by race and ethnicity Black and Latinx women are more likely to live below the poverty level compared to their White peers.40 The high and disparate rates of women living below the poverty level means many Oklahoma women have limited or non-existent access to health care, safe housing, healthy food, and financially stable work. Of all women, Black transgender women are the most likely to live in poverty, with 34 percent living in extreme poverty nationwide as of 2017.43 What We Can Do: - Raise Oklahoma’s minimum wage - Support federally proposed job guarantee program

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Data Highlight: Oklahoma is the fifth-most food insecure state. New Hampshire has the lowest rates of food insecurity at 7.8 percent while New Mexico has the highest rate of food insecurity at 16.8 percent.48

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Food Insecurity

DEFINITION

A lack of access to a store containing fresh produce within a 10 mile radius if living in a rural area, and 1 mile radius if living in an urban area for 2016-2018.48

OKLAHOMA 15.6 percent

NATIONAL AVERAGE 11.7 percent

Why We Care: While often discussed as a social or economic issue, food insecurity is especially detrimental to women’s health, and can lead to depression, anxiety, and obesity.49 As women earn less than their male counterparts and head more single-headed households with children, women are more likely to experience food insecurity.49 Factors contributing to food insecurity and inconsistent access to food can include lack of grocery stores in the part of town (or nearby) in which you live, lack of transportation, and lack of financial resources.49 Individuals living in food-insecure homes can have anxiety about food as eating patterns can be irregular due to inconsistent access to food. 50 When women are pregnant, food insecurity can cause myriad health problems from iron deficiency to gestational diabetes and low birthweight.49

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What We Can Do: - Separate food programs from public charge rules - Incentivize grocery store development in food desert areas - Create requirements so current chain discount stores must sell fresh produce - Support local and urban farming food growing initiatives

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DEFINITION

The percent of female head of households, that are single parent h o u s e h o l d s r e p o r t e d i n 2 0 1 9 . 51

OKLAHOMA 69.7 percent

NATIONAL AVERAGE 70.9 percent

Single Parent Head of Households Data Highlight: Across the nation, 80.6 percent of Black mothers are breadwinners, bringing in at least 40 percent of their overall

household income.52 Why We Care: Due to the gender wage gap, single mothers are more likely to live in poverty than single fathers. On average, women earn less money each year, and over the course of their lifetimes, than their male counterparts.46 A typical woman working from age 17 to 70 will earn over half-a-million dollars less than a typical man. In a situation where a family depends solely on a woman’s wages, this is a troubling trend that impacts the health and well-being of the children and the mother in the household. Nearly two-thirds of poor children live in single-parent household, with 59.5 percent of those being single-mother households.51 What We Can Do: - Develop public options for childcare and/or expand access to free and reduced cost childcare programs - Continue to expand and improve paid family leave policies so if a woman needs to stay home with a sick child, her income is less impacted

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Gender Pay Gap

DEFINITION

The amount of money that all women make, per every dollar that white, nonLatinx men make (as of 2019). 52

OKLAHOMA

Data Highlight: “Indigenous women are typically paid 60 cents, Black women 63 cents, and Latinx women just 55 cents for every dollar paid to white, non-Latinx men.”52

73 cents paid to all women, for every dollar made by white, non-Latinx men

NATIONAL AVERAGE

82 cents paid to all women, for every dollar made by white, non-Latinx men

Why We Care: It has been several decades since women have joined the workforce, and while women have nothing further to prove, one might not get that impression if evaluating the discrepancy women continue to face in pay. This is especially true for women of color, who face even more severe pay discrimination than their White counterparts. 53 Though more families are now splitting household responsibilities, many women are still the primary caregivers for children. 46 If equal pay were a reality in Oklahoma, the poverty rate for working women in the state would be reduced almost by half and their earnings would increase by about $5.4 billion a year.46 Equal pay for equal work would not only close the gender wage gap, but also allow Oklahoma’s women to better afford health care, housing, food, and a life above the poverty level. Addressing pay equality and secrecy is a crucial part of closing the gender wage gap, and protection from retaliation would be a very positive step forward for women’s economic security.

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What We Can Do: - Support legislation that promotes pay transparency for all Oklahoma women - Expand the number of licensed childcare facilities - Invest in quality improvements in childcare

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DEFINITION

The average cost for center-based infant care as a percentage of married couple’s median income. 54

Cost of Child Care

OKLAHOMA

11.7 percent

Data Highlight: Mississippi has the lowest average cost for center-based infant 11 percent care as the average cost of child care was 7.6 percent of the household income, while California has the highest average cost for center-based infant care as the cost of child care was 17.5 percent of the household income. 54 NATIONAL AVERAGE

Why We Care: Thanks to broad cultural shifts over the past several decades, families are now splitting household responsibilities, though many women are still the primary caregivers for children. Affordable child care is becoming less available in Oklahoma, and some families find that it makes more financial sense for one parent to leave their job and stay at home to care for children.54 When families make that decision, it is much more likely that the stay at home parent will be a woman. With the rising number of single-parent homes, there is no stay-at-home option.46 Even when the caregiving responsibility is temporary and women can return to work later, the temporary absence from the workforce still means that their lifetime earnings will be less than they would have otherwise been. For women who are able to return to work, the childcare accessible to them may be substandard. In response to the demand for more affordable care, ad hoc childcare centers run out of homes have become more common, where most of these lack the licensing and accreditation promised in commercialized facilities.54 What We Can Do: - Support the Earned Income Tax Credit to ensure families have the financial resources to pay for child care - Expand the number of licensed childcare facilities. - Invest in quality improvements in childcare

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Substandard Housing

DEFINITION

The percentage of occupied housing units with at least one of four problems: lack of complete kitchen facilities, lack of plumbing facilities, severely crowded, or severely cost-burdened occupants (Estimated from 2013-2017 data).55

Data Highlight: OKLAHOMA 14 percent Oklahoma ties with Wisconsin for rank 15 (of 50) for substandard housing. Nationwide, communities of color, NATIONAL AVERAGE 17.5 percent the formerly justice involved, and members of the LGBTQ+ community are some of the most likely to experience housing discrimination across the nation, which narrows the availability of safe and affordable housing for these groups. 55,56,57

Why We Care: Substandard housing poses risks to the health, safety, and well-being of occupants. 55 Unhealthy conditions in substandard housing can include the presence of lead, radon gas, carbon monoxide, mold, pests like cockroaches, bedbugs, and rats, and poor temperature control. These unsafe surroundings can cause lead poisoning, allergies, cancer, illnesses, asthma, and other respiratory issues.55 These health issues often result in missed school or work for occupants. Unfortunately, most occupants of substandard housing are at or below the poverty line, and because of the economic discrepancies women in Oklahoma face, women, particularly women with children, are more likely to live in substandard housing in Oklahoma. Populations of color, the formerly justice involved, disabled, and members of the LGBTQ+ community are some of the most likely to experience housing discrimination across the nation, which narrows the availability of safe and affordable housing for these groups.55,56,57,58

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What We Can Do: - Work with cities and municipalities to report and address instances of substandard housing - Work to improve laws, rules, and codes around housing conditions to ensure tenants are not as frequently subjected to substandard and unsafe housing conditions - Enforce anti-discrimination housing laws

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DEFINITION

The percent of female-headed households that received Supplemental Nutrition Assistance Program ( S N A P ) i n t h e p a s t 1 2 m o n t h s i n 2 0 1 9 . 56.

Female SNAP Recipients

OKLAHOMA

Data Highlight: The state of Wyoming has the lowest rates of SNAP use amongst NATIONAL AVERAGE female-headed households at 18.2 percent while West Virginia 29.7 percent has the highest rate of use at 43 percent. Oklahoma ranks 44 of 51 of SNAP use for female-headed households in the past 12 months. 44 34.5 percent

Why We Care: Supplemental Nutrition Assistance Program (SNAP), formerly known as “food stamps,” is an effective tool to support families in poverty. Unfortunately, due to the wage gap, women are more likely than men to experience poverty and need SNAP benefits to make ends meet each month. Single women without children between the age of 18-49 qualifying for SNAP benefits are only able to access the invaluable nutrition assistance for a three month period. 45 Making lower wages than male counterparts doesn’t change for women once they have children and single femaleheaded households are the most likely household composition to live at or below the poverty line. Approximately 78 percent of SNAP households include children, a person with a disability, or someone elderly.46,47 SNAP benefits assist with improving the health and well-being of families through providing necessary nutritional support during an economic rough patch. What We Can Do: - Separate food programs from public charge rules - Expand education and access to SNAP services - The State could reverse its decision to prohibit itself from applying for a waiver that would allow able-bodied single women to receive SNAP benefits for longer than the three month limit if they reside in an area where it is hard to find consistent work - Support comprehensive Medicaid expansion initiatives - Advocate for a livable minimum wage

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Education Access to and completion of comprehensive education can dramatically change the trajectory of a woman’s life. When women can complete higher levels of education, they are more likely to be financially stable and healthier. However, for too many women, the barriers in accessing higher levels of education are numerous. In Oklahoma only 31 percent of the population has a Bachelor’s degree or higher, and those with higher education are concentrated. The counties containing the highest rates of individuals with higher education are Tulsa, Payne, Cleveland, and Oklahoma. While a Bachelor’s degree is not the solution to women’s economic or health issues, it helps ensure many Oklahoma women are in jobs that pay enough to survive. The median income in Oklahoma is $49,767.00, which allows a household, especially one with children, to barely scrape by.42 While women with college degrees generally make more than their counterparts with high school diplomas, they can still experience significant financial hardship. Additionally, those who incur student debt to pay for college, but do not attain a degree, experience financial burden without benefit. Student loan debt, and whether or not a woman has completed a degree she borrowed loans to pursue can ultimately end up destabilizing a woman’s financial circumstances. In these instances, attending college has been proven to put women, especially Black and Brown women, in a potentially worse economic position than if they hadn’t attended at all.59 Women accessing education has led to further equality in our society, and we should work to make education more accessible and affordable for all.

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DEFINITION

The percent of women 25 years of age or older with no high school diploma or equivalent (dropout rate proxy) for the year 2019.64

OKLAHOMA

High School Drop-Out Rate

11 percent

Data Highlight: Oklahoma ranks 38 (of 51) in drop-out rate for women. 10.8 percent Wyoming reports the best outcome at 4.9 percent, and California reports the worst at 15.7 percent of women with no high school diploma or equivalent.64 NATIONAL AVERAGE

Why We Care: While the high school dropout rate is strongly correlated with a host of negative health outcomes, the phenomenon is especially harmful to women. Women who do not complete high school are more likely to struggle financially than their male counterparts when factoring in the wage gap between men and women at all levels.65 Adults over the age of 25 who dropped out of high school report that they are in worse health than the reports of those who did not drop out. This is consistent with research that shows that individuals who complete high school experience far fewer chronic health conditions in their lifetime.65,66 For women especially, teen pregnancy contributes to drop out rates as the role of parenting can be stressful and demanding, and teen mothers often have access to fewer supports than older parents. 26 What We Can Do: - Ensure students have access to a broad range of services to help them plan and achieve long term goals - Provide specialized support for expecting and parenting young adults

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DEFINITION

Percent college-level educational attainment of female adults aged 25 years or older, reported in 2019.60

Lookbook Vol. 2

Women with a College Degree

OKLAHOMA 35.8 percent

NATIONAL AVERAGE Data Highlight: 43.4 percent “Between 2004 and 2014, the share of Black women with a bachelor’s degree or higher increased by 23.9 percent nationwide, making Black women the group of women with the second-largest improvement in attainment of higher education during the decade.” 60,61 Why We Care: Education is a social determinant of health that is linked to higher wages. 62 The ability to make higher wages in a more stable job can reduce stress and increase a woman’s ability to afford healthier foods, safer living options, and in Oklahoma’s current Medicaid non-expansion state, continuous health care. Educational attainment provides many Oklahoma women with security and independence, however, outcomes can be bleak for women who access higher education, but do not earn a degree.62 Black women are more likely than any other racial or ethnic group to access higher education, with a 23.9 increase in degree attainment between 2004 and 2014, but are the second-highest ranked in completion.61 Accessing higher education but not earning a degree can create financial hardship as the combination of student loan borrowing without degree attainment can thwart higher earnings and increase debt. 60,63

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What We Can Do: - Increase access to careers in science, technology, engineering and mathematics (STEM), skilled trades, and other disciplines that are in demand, with high earning potential, where women are underrepresented - Advocate for fair pay in professions that are predominated by women - Maintain federal grants that provide support for parenting students

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DEFINITION

The percentage of teen mothers who had at least two births by the age of nineteen in 2017. 8,36

Subsequent Teen Births

OKLAHOMA

Data Highlight: NATIONAL AVERAGE *2017 data are used for this national comparison. At the time of 23.3percent* writing, preliminary 2018 data were released by the Oklahoma State Department of Health, showing a 28.6 percent decrease from 2017 to 2018 in subsequent teen birth, falling from 23.8 percent to 17 percent. 8,36 23.8 percent*

Why We Care: While not a traditional academic indicator, subsequent teen births are strongly correlated with lower educational attainment. Oklahoma’s rate for subsequent teen births is higher than most states, though that number appears to be declining. 8 As of 2018, nearly one in five teen births in the state of Oklahoma are repeat births. Repeat births to teens significantly affect young women’s ability to graduate from high school, even when compared to their peers with one child. 70 In 2017, Oklahoma became the recipient of the Pregnancy Assistance Fund, a federal grant designed to create support networks for young parents seeking to graduate from high school and accomplish life goals.71,72 Programs that emphasize goal setting, and encourage young parents to meet their educational and employment goals before having another child have shown effectiveness in preventing subsequent teen births.71,73 What We Can Do: - Support life skills and enrichment programs such as the Tulsa-based program, “Strong Tomorrows,” an organization that specifically supports young mothers with multiple children

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Data Highlight: Oklahoma ranks 39 (of 50). Iowa has the best high school graduation rates at 91.4 percent, and New Mexico has the worst with 73.9 percent of women graduating high school within four years.67

DEFINITION

Th e p e rc e n t a g e o f a l l s t u d e n t s who graduated from high school within four years of starting high school reported for 2017. 67

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High School Graduation Rates

OKLAHOMA 81.8 percent

NATIONAL AVERAGE 85.3 percent

Why We Care: Better jobs with greater earning potential are just the beginning of the benefits for women who graduate from high school. Emerging evidence also suggests that the actual process of being educated is good for your health, specifically those who experienced early childhood trauma. 68 Stress reduction and increased access to health and social services are partly to credit. 68 Additionally, the networks that young people build in high school expose them to new ideas and pathways to opportunities they may not have previously had access to or thought possible for their education.69 For teen mothers, their degree attainment also has general benefits for their children. 69 The children of teen mothers who had graduated from high school are more likely to graduate themselves than those whose mother dropped out.38

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What We Can Do: - Advocate for more per pupil funding in public schools and up-to-date adjustments to the state funding formula - Advocate for more funding for social workers and counselors in schools

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Foundational Health Many Oklahoma women do not have consistent health care coverage and for those who do have private insurance, deductibles and other out-of-pocket expenses can be so costly they may forego care in favor of economic stability. Irregular care means many women do not have the opportunity to be as healthy as they could be, and also means that if they become pregnant, they begin the pregnancy in poorer health. In Oklahoma, if a woman is pregnant and has an income of or less than 200 percent of the Federal Poverty Level—which for a household of two is $3,017.00 monthly before taxes—and meets the other program requirements, she can receive SoonerCare coverage.74 Unfortunately, when not pregnant, many of these women find themselves in what is known as the ‘coverage gap’. In Oklahoma, adult women are not covered by SoonerCare unless they have children, and if they have a household of three, make less than $797.00 a month before taxes. 74 For those women who make more than the established income limits, but too little to afford private health insurance fall in the coverage gap, and have no health care coverage. Looking towards the future, those in this coverage gap may benefit from forthcoming healthcare coverage options when Medicaid expansion in fully implemented in Oklahoma. Today, the reality is that while some employers provide coverage, it can still be a struggle to cover the cost of high deductibles. All of these barriers to health care create the environment for low birthweight infants, maternal and infant mortality, and unaddressed tobacco, alcohol, and other substance use yielding various chronic conditions.

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DEFINITION

The percent of women who identify as current smokers for the year 2019.3

Women Who Smoke

OKLAHOMA

Data Highlight: NATIONAL AVERAGE Smoking tobacco is taxed 80 percent of its factory list price in 13.5 percent Oklahoma. This tax has been proven to reduce the number of smokers, but is also criticized as disproportionately affecting lower-income smokers. 80 17.2 percent

Why We Care: Smoking increases health issues and the likelihood someone who smokes will get certain diseases. Women who smoke are at greater risk of dying of heart disease, COPD, or an abdominal aortic aneurysm caused by a weakening of the blood vessels than men. Additionally, reproductive issues can plague women who smoke and they’re more likely to contract cervical cancer than their nonsmoking counterparts.81,82 In Oklahoma 17.2 percent of the adult female population currently smokes compared to 13.5 percent nationwide. When women stop smoking they lower their risk of stroke, cervical and lung cancer, heart disease, and diabetes. They see improvement in their immune system, ability to taste and smell, lung capacity, and blood pressure level. 82

What We Can Do: - Connect women with resources to help them quit smoking - Ensure community clinics in underserved communities are well-staffed and able to facilitate positive, culturally-competent, long-lasting relationships with their patients through culturally informed practices

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OKLAHOMA

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Poor Health Perceptions

DEFINITION

The percent of women reporting fair or poor general health in 2018.3 23.6 percent

Data Highlight: NATIONAL AVERAGE “Healthcare Gaslighting” is a term that describes how women 19.4 percent are more likely to be told that their perception and experience of their bodily well-being is inaccurate or not of serious concern. This phenomenon can result in poor health outcomes. 77 Why We Care: How women interpret their health is an often overlooked factor in determining their health outcomes. Well-intentioned clinicians can often undermine the bodily perceptions of female patients who present with symptoms that appear to be caused by stress or anxiety, and women are more commonly told that their ailment is “all in their heads”. 75 This phenomenon has been documented for well over a decade, and is common enough to have its own name: Healthcare Gaslighting.75 Going back as far as 2001, a study showed that women were prescribed less pain medication than men after identical procedures, and were less likely to be admitted to the hospital when presenting with the same symptoms.76 For women of color, this phenomenon is especially dire, as Black and Indigenous women are more likely to die from pregnancy-related health problems, even when socioeconomic variables are controlled.78 As one affected woman explained to Oprah Magazine, “While not every Black woman has had experiences like these, they’re disappointingly familiar to legions of us.79 Indeed, there is enough anecdotal and factual evidence to suggest that a dangerous color-based bias is baked into the American healthcare system, affecting even well-educated, upper-middleclass patients—the type you might expect to be immune from such inequity.” 78

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What We Can Do: - Create standards of care that ensure an objective response to women’s sense of their bodily anatomy and feelings about their personal health - Educate on the harm of the “hysterical woman” stereotype in a clinical setting, especially as this relates to medical care provided to Black and Indigenous women

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DEFINITION

Percentage of women ages 18-44 who reported doing no physical activity or exercise other than their regular job in the past 30 days reported in 2018.85

Physical Inactivity

Data Highlight: 35.6 percent Oklahoma ranks 49 (of 50) in physical activity. Women in NATIONAL AVERAGE Colorado are most active, with a rate of 18.6 percent of women 23.5 percent reporting inactivity. Mississippi women are the most likely to report inactivity, with a rate of 31.6 percent. 85 OKLAHOMA

Why We Care: Physical activity is one of the best preventative actions for women to improve their overall health and well-being. A wide range of health benefits have been proven, from lessening the symptoms of depression, keeping the mind sharp, helping manage weight, improving bone health, and protecting against chronic disease among many others.86 While the benefits are vast and well-documented, Americans often report that they are unable to find time to exercise. Studies have reported that women perceive having less time to exercise than men, and are less likely to take part in recreation due to competing obligations.87 Women within marginalized racial and ethnic groups, or those living in low-income environments are least likely to report finding adequate exercise. 87 The reasons are complex and are partially due to limited access to parks and recreational amenities, concerns of neighborhood safety, and very limited time and energy for self care practices like physical activity.87 What We Can Do: - Increase access to community centers, public parks, and low or no-cost amenities that boost physical activity - Further subsidize sliding scale community fitness centers and gym memberships, allowing for economically disinvested communities to further participate - Minimize stereotyping and heuristics by educating on the many complex reasons some individuals are less active (that have little to do with motivation)

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Data Highlight: Oklahoma ranks 47 (of 51) for prevalence of obesity in women. Women in Colorado have the lowest rate of obesity at 23.8 percent, and women in Mississippi have the highest rates at 40.8 percent of all women.8

DEFINITION

Women reporting a body mass index (BMI) greater than 30, for 2018. 8

OKLAHOMA

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Obesity in Women

36.8 percent

NATIONAL AVERAGE 31.9 percent

Why We Care: As a state, Oklahoma struggles with rates of obesity that are higher than the national average. There are a variety of factors contributing to obesity in Oklahoma, making it a complex health issue to address. Some of these factors include the ability to access and participate in regular physical activity and maintain a healthy diet. Other factors, like community environment and economic opportunity play just as important a role. 84 For women who do not have extra funds to spend on gym memberships, built environments can provide the opportunity to exercise. However, Oklahoma is not a pedestrian or cycling-friendly state; most of the state is rural and sprawling, and in urban areas consistent sidewalks and bike lanes are lacking. Additionally, many Oklahoma women live in food deserts, making it more difficult and expensive to access fresh fruits and vegetables. 84 Lack of access to healthy food, adequate wages to buy healthy food, and environments that support healthy movement and physical activity comes at a cost for Oklahoma women affected by obesity. Some of the health consequences of obesity include high blood pressure, Type 2 diabetes, heart disease, stroke, and mental health problems like depression and anxiety. Obesity impacts Oklahoma women’s physical, mental, and economic health. 84

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What We Can Do: - Improve access to parks, bike lanes, and sidewalks - Ensure that communities have access to full grocery stores, and less “dollar” convenience stores - Increase access to community centers, public parks, and low or no-cost amenities that boost physical activity - Further subsidize sliding scale community fitness centers and gym memberships, allowing for economically disinvested communities to further participate

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Maternal and Child Health As a state, Oklahoma cares a lot about the health of children and families. Often, it seems that Oklahoma overlooks the important role a mother’s health plays in the health of a family. When women are healthy, they begin and have healthier pregnancies, healthier births, and healthier babies. A mother’s regular doctor visits increase the likelihood the baby will be born full term. A birth closer to full term allows the baby to gain weight that aids in crucial physical and cognitive development, lessening the likelihood the infant needs emergency care once born and increasing the chances the infant will survive its first year. Without consistent health care coverage, many women can not regularly see a doctor or treat chronic illnesses causing women to begin pregnancies in poorer health and increasing the risk of complications, including death. In 2018, Oklahoma ranked 47th for its infant mortality rate of 7.8 per 1,000 live births, and 47th for its maternal mortality rate of 23.4 per every 100,000 women .23 When the data comprising these rates are disaggregated by race, the disparities revealed are appalling. In Oklahoma, Black women are nearly three times more likely to die of childbirth-related causes and Black babies are twice as likely to die than their White counterparts. This atrocious disparity can be addressed as most infant and maternal mortality is preventable. Some of the primary causes of maternal mortality are hemorrhaging, infection, heart conditions, and mental health disorders and they can be prevented if women have more consistent health care coverage and access. Consistent health care coverage through Medicaid expansion provides better access to prenatal and postnatal care, for both physical and mental health needs, reducing the likelihood of infant and maternal mortality.

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Pregnancy, giving birth, and raising a child are physically and mentally demanding. Working to address social determinants of health like the ability to access health care, can be life saving for many Oklahoma women and children. Ensuring mothers can access continuous health care and easily access other support, like Women, Infants and Children nutrition program during the early stages of their children’s lives helps create stronger, healthier families.

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DEFINITION

Preterm birth is defined as a birth that happens before 37 weeks gestation for women of reproductive age reported in 2019.8

OKLAHOMA 11.5 percent

NATIONAL AVERAGE 10.2 percent

Preterm Births Data Highlight: Oklahoma ranks 45 (of 50) for preterm births. New Hampshire has the lowest preterm birth rate, 8.2 percent, and Mississippi has the highest at 14.6 percent.8

Why We Care: Complications due to preterm birth is a leading cause of infant mortality in the state. Preterm birth can be prevented and is connected to the health and well-being of the mother .88,89 While there are several reasons why a preterm birth happens, some of the more common reasons preterm births occur are related to high blood pressure, diabetes, poor nutrition, stress, domestic violence, smoking, substance use, and maternal age. When women have access to continuous health care before, during, and after pregnancy, nutritious food, and healthy, robust social support systems, the likelihood of having a preterm birth decreases .88,89,90 What We Can Do: - Ensure the implementation of Medicaid expansion includes provisions that covered women before giving birth, increasing the likelihood they will begin pregnancies in better health and their babies will be healthier - Ensure access to mental health resources before, during, and after pregnancy so women experience stress or mental health issues can access care for concerns - Increase Medicaid reimbursement rates so doctors do not feel as limited by the cost of care they can provide

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Data Highlight: Oklahoma ranks 25 (of 51) for low birthweight. Alaska was ranked first with the lowest low birthweight outcomes at 6.2 percent, and Mississippi reported the worst outcomes at 12.3 percent.8

DEFINITION

Low birthweight is def ined as a baby born weighing less than 2500 grams. These data are for 2019. 8

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Low Birthweight

OKLAHOMA 8.2 percent

NATIONAL AVERAGE 8.3 percent

Why We Care: The health of Oklahoma women impacts the health of their children. Infant birthweight is impacted by several factors including the mother’s access to proper nutrition, smoking habits, stress levels, and ability to receive regular prenatal care. The consequences for low birthweight infants can be dire, and include respiratory distress syndrome, bleeding in the brain, intestinal issues, and damage to the retina.39 Later in life, these complications can lead to diabetes, blindness, deafness, heart disease, and breathing problems, among several other conditions.39 In essence, low birthweight babies are born without adequate time to develop, often leading to chronic illness later in life. Most alarming, Black women are twice as likely to have low birthweight baby than their White peers. Research designed to control for environmental factors has found that this disparity exists due to the effect historical and institutional trauma has on the mother’s, then the baby’s health .88

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What We Can Do: - Better address known social and environmental risk factors - Research on how historical and institutional racism affects preterm births and low birthweight in historically marginalized communities

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DEFINITION

Women who report using tobacco while pregnant reported for 2019. 8

OKLAHOMA

Tobacco Use in Pregnancy

10.9 percent

Data Highlight: Oklahoma ranks 35 (of 51). California women are the least likely 6.5 percent to use tobacco while pregnant, at 1.3 percent, and women in West Virginia are the most likely to use tobacco while pregnant, at 23.9 percent .8 NATIONAL AVERAGE

Why We Care: Pregnancy can be stressful, and using tobacco during this time can be a reassuring habit and unhealthy form of stress release. Additionally, messaging around the best way to quit during pregnancy has been convoluted in recent years, leaving many mothers confused about their best course of action. Despite this, it is certain that tobacco use during pregnancy can lead to preterm birth, contribute to low birthweight, and cause mouth and lip birth defects. Tobacco use can also adversely impact women’s health while pregnant causing complications like high blood pressure, and dangerous movement of the placenta.82 In Oklahoma, the number of women who use tobacco while pregnant- 10.9 percent of the population-is nearly twice as high as the national average of 6.9 percent. The level of tobacco use while pregnant in Oklahoma causes the State to rank 35th of the 50 U.S. states and Washington D.C.82 What We Can Do: - Connect moms to the 1(800)Quit-Now hotline, or similar resources, so they can access counseling, gums, and patches

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Data Highlight: Oklahoma ranks 39 (of 51) for healthy birth spacing. Massachusetts ranks first with only 5.1 percent of women birth spacing less than eighteen months, and Mississippi has the most room for improvement with 9.7 percent of women birth spacing less than eighteen months.8

DEFINITION

Birth spacing refers to the time from one child’s birth until the next pregnancy, also known as the interpregnancy interval. 18 months is generally considered adequate time for a next birth to occur. These data are from 2019. These data represent the number of women birth spacing less than eighteen months. 8

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Healthy Birth Spacing

OKLAHOMA 8.1 percent

NATIONAL AVERAGE 7.1 percent

Why We Care: Pregnancies that start less than 18 months after a previous birth are associated with delayed prenatal care and adverse birth outcomes. These unfavorable birth outcomes include preterm birth, neonatal morbidity, and low birthweight .70 In addition, children born without at least 18 months of birth spacing are at greater risk of developing asthma, vision and hearing loss, and may experience developmental delays. Between 2006 and 2010, about 33 percent of pregnancies nationwide were not adequately spaced, a practice that can put both the mother and baby at risk .70,71

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What We Can Do: - Support organizations that promote scientific, evidence-based prenatal and perinatal practices - Providers can discuss and help women develop contraception plans and birth spacing options during prenatal visits

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DEFINITION

Number of deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within one year of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 100,000 live births (5-year estimate from 2013-2017).23

OKLAHOMA

33.9 deaths per 100,000 women

NATIONAL AVERAGE

29.6 deaths per 100,000 women

Maternal Mortality Data Highlight: Nationwide, Maternal Mortality is three times more common for Black and Indigenous women than White women. Oklahoma is ranked 38 (of 50) for its maternal mortality outcomes. Alaska has the best outcomes at an average of 12.4 deaths per 100,000 live births per year, and Louisiana ranks the worst at 72 deaths per 100,000 live births per year.23

Why We Care: “I was starting to think I might not be around to raise my daughter,” accounted Whitney, an expecting mother and PhD candidate who recalls poor healthcare interactions during unexpected complications throughout her pregnancy.79 Whitney’s story personifies how Black women, even when highly educated, in good health, and financially stable, are still far more likely to die due to complications from childbirth than White women of lesser education and financial stability.78 In Oklahoma Black and Indigenous women are three times more likely to die from childbirth or childbirth-related complications than their White counterparts.78,79,93 The Oklahoma Legislature passed a bill in 2019 establishing a Maternal Mortality Review Committee (MMRC). Since November of 2019, the MMRC has been reviewing, identifying, and providing recommendations to address the underlying, preventable causes contributing to the death of Oklahoma mothers. States that previously established these committees have found that most maternal mortality was preventable and made changes accordingly.93,94 These changes have decreased rates of morbidity, too, which is defined as “severe, near-death experiences”. Though morbidity does not end in death, many situations causing morbidity could end in mortality if they’re not caught and addressed soon enough to save a mother.93

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What We Can Do: - Work to require providers at all levels of care to complete a series of bias training on a regular basis to be aware of how their biases present in their patient interactions and dialogue - Support organizations working on reproductive justice issues and reducing Black and Indigenous maternal mortality - Improve measurement of severe, birth-related, near death experiences women in our state face each year

OKLAHOMA 2.7 per 1,000 live births Data Highlight: Oklahoma ranks 32 (of 51) states and territories in neonatal NATIONAL AVERAGE 2.4 per 1,000 live births death. New Hampshire has the best outcomes related to neonatal death, at 1.4 per 1,000 live births, and Utah has the poorest outcomes, reporting 4.8 neonatal deaths per 1,000 live births.23

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Neonatal Death

DEFINITION

Death of an infant within 28 days of birth, per 1,000 live births between 2016-2017.23

Why We Care: Neonatal death, the death of an infant within 28 days of birth, is a tragedy. Neonatal death is commonly caused by complications the baby faces after a premature birth, due to low birthweight, or because of birth defects.91 While birth defects are rarely preventable, premature birth and low birthweight can be prevented. When women can access health care regularly, begin pregnancy in a healthier state, and receive earlier (in the first trimester) more consistent prenatal care, babies are born closer to term at healthier weights.91,92 Currently, when compared to the other states and Washington D.C., Oklahoma ranks 32th for neonatal death.23 Over the years Oklahoma has improved its ranking, but there is still more to be done.

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What We Can Do: - Expand Medicaid so women are covered before giving birth, increasing the likelihood they will begin pregnancies in better health and their babies will be healthier - Increase Medicaid reimbursement rates so doctors do not feel as limited by the cost of care they can provide

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DEFINITION

Percentage of mothers who maintained breastmilk only nutrition for the first six months of an infant’s life in 2017.126

OKLAHOMA 23.7 percent

NATIONAL AVERAGE 25.6 percent

Exclusive Breastfeeding Data Highlight: Minnesota had the highest rates of Exclusive Breastfeeding at 38.7 percent, with Mississippi being the lowest at 18.1 percent. Oklahoma ranks 36 of 51 for Exclusive Breastfeeding.126

Why We Care: Exclusive breastfeeding (EBF) leads to healthier babies and mothers. EBF, or breast milk only nutrition for the first six months of an infant’s life, 127 is recommended by major health organizations worldwide along with continued breastfeeding up to 1-2 years.128 Studies show EBF reduces the risk of diabetes and obesity in mothers and children, two leading chronic health concerns in Oklahoma. It has also been shown in babies to reduce the risk of sudden infant death syndrome (SIDS), childhood cancers, and common illnesses like ear, respiratory and gastrointestinal infections. 129,130 Increasing breastfeeding rates is a major objective of the Oklahoma State Department of Health as part of their efforts to reduce Oklahoma’s tragically high infant mortality rate. 131 If 80 percent of Oklahoma infants were exclusively breastfed for the first six months, it would save 30 maternal and nine child lives each year. In addition, it would save over $33 million in annual medical costs. 132 What We Can Do: - Educate new moms on the benefits of exclusive breastfeeding - Encourage women’s health clinics and physicians to promote EBF to their patients - Enact policies that make it easier for nursing mothers to breastfeed while at work and away from home

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Mental Health Mental health and substance abuse treatment services and facilities are under resourced in Oklahoma, and individuals in need of treatment must overcome too many barriers to seek adequate treatment. Although the actual rate of providers in Oklahoma is much higher than the national average (411.3 per every 100,000 residents), this number is misleading as it includes those who no longer practice, as well as clinicians who choose to work in private industry.7,11 It also doesn’t account for the rates of substance abuse in the overall population. In contrast to a large provider network, Oklahoma is experiencing a shortage of psychiatrists across the state, and capacity to treat all who need care at mental health treatment facilities.11 These issues are further compounded by the limited access to health care coverage faced by many Oklahomans. Due to this, too many Oklahomans cannot access preventative care, the care they need during a mental health crisis, or substance abuse treatment when they are ready and wanting to begin the road to recovery.7 The reasons women in Oklahoma struggle with mental health issues are complex and compounding. As the state with the fifth-highest rate of two or more adverse childhood experiences (ACEs), Oklahoman women experience stress, anxiety, depression and other chronic health conditions associated with early childhood trauma.7,26 There is also compelling evidence to suggest that trauma and justice involvement go hand-in-hand. This would make sense for Oklahoma, as it leads the world in the number of women who are incarcerated per capita.111

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DEFINITION

Percentage of women ages 18-44 who reported either binge drinking (having four or more drinks on one occasion in the past 30 days) or chronic drinking (having eight or more drinks per week).4

OKLAHOMA 14.3 percent

NATIONAL AVERAGE 19.2 percent

Binge Drinking Data Highlight: Oklahoma ranks 5 (of 50) in binge drinking amongst women. Mississippi and Utah tie for the lowest rates of 12.2 percent of all women, and Massachusetts has the highest rates of binge drinking for women, at 27 percent.4

Why We Care: Addressing the root cause of alcohol use and the physiology of addiction will help improve outcomes for women consuming alcohol at unhealthy levels or experiencing alcohol dependence. Oklahoma has some of the lowest rates of binge drinking among women in the nation.99,100 However, our rates of alcohol consumption during pregnancy require particular improvement. Drinking alcohol during pregnancy can cause fetal alcohol spectrum disorders, increasing the likelihood a baby is born with birth defects, the mother could miscarry, or have a stillbirth.99 While drinking early in a pregnancy before the mother discovered the pregnancy can happen, it doesn’t necessarily lead to drinking throughout the pregnancy. For the 20.3 percent of Oklahoma women who reported using alcohol during the last three months of pregnancy, having the support of others and counseling can help improve both theirs and their baby’s future health.99,100 What We Can Do: - Continue to increase funding for mental health and substance use treatment so women can access counseling and treatment services for alcohol use disorder - Provide education on alternative stress reduction and mindfulness activities - During prenatal check-ups, utilize a brief screening and counseling intervention, providing women with treatment options and education on the side effects of consuming alcohol while pregnant

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Data Highlight: Postpartum depression can arise anywhere from 2 weeks to 1 year after giving birth. Misconceptions about the timing of the postpartum period often lead to underreporting of postpartum depression.96

DEFINITION

The percentage of women with a recent live birth who reported experiencing depressive symptoms in 2016-2017.96

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Postpartum Depression

OKLAHOMA 15 percent

NATIONAL AVERAGE 12.5 percent

Why We Care: Pregnancy and birth are physically and mentally demanding. During pregnancy and after giving birth, hormones and sleep patterns change, and new stresses can emerge like additional financial concerns, returning to work, and finding and paying for reliable childcare options. Additionally, if a woman has experienced depression-like symptoms before pregnancy, those symptoms can reemerge or increase during pregnancy. If a woman is able to access prenatal health care during pregnancy, a primary care physician or obstetrician can help address these symptoms. However, postpartum depression can arise anywhere from 2 weeks to 1 year after giving birth.96,97 Some Oklahoma women, that are eligible for SoonerCare, Oklahoma’s Medicaid, will lose their healthcare coverage just two months after they give birth.96,97 Limited coverage during the postpartum period means that for many Oklahoma women, they have one follow up appointment with a doctor, but then do not have contact with a medical professional who can help diagnose and treat any postpartum mental health issues that arise.96 In 2019 the Oklahoma state legislature passed SB 419 requiring physicians to screen women for depression during pregnancy and pediatricians to screen mothers during their children’s well baby visit, which will help ensure that clinicians screen for postpartum depression.98

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What We Can Do: - More intentionally publicize and support the enrollment processes for private, Tribal, and public (SoonerCare, Insure Oklahoma) insurers along with other localized resources providing pathways for early entry into prenatal care - Ensure that implementation of Medicaid expansion includes comprehensive coverage for postpartum mental health services

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DEFINITION

The age-adjusted number of deaths due to drug injury (unintentional, suicide, homicide or undetermined) per 100,000 females ages 15-44 in 2018.39

OKLAHOMA

19.6 per 100,000 females ages 15-44

NATIONAL AVERAGE

20.3 per 100,000 females ages 15-44

Drug Related Deaths Data Highlight: Oklahoma ranks 26 (of 50) for women who have died due to a drug related injury. Hawaii has the lowest rate reported at 6.9, and West Virginia has the highest rate reported at 65.4 per 100,000 females ages 15-44.39

Why We Care: Substance use disorders are a chronic illness. Substance use changes the natural chemical balance in the brain and a person’s physiology, making it difficult, if not impossible to stop using a substance once a body’s need for a given substance has developed.106 The road to recovery is long and often filled with relapses, a very normal part of working toward sobriety. Too many women in Oklahoma are dying due to drug-related injury, which includes unintentional, suicide, and homicide deaths.106,107 Some of these deaths could be prevented if women had access to a variety of treatment options, including easier access to medication-assisted treatment (which is an effective, evidence-based treatment for opioid use disorder).107,108 What We Can Do: - Ensure that the implementation of Medicaid expansion includes increased access to treatment - Work to de-stigmatize medication-assisted treatment - For those in clinical settings: work with fellow doctors, physician assistants, and registered nurses to complete buprenorphine training, making it possible to provide a medication-assisted treatment option in your clinic

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Data Highlight: Oklahoma ranks 41 (of 51) for frequent mental distress. South Dakota ranks the lowest at 10.6 percent, and New Hampshire ranks the highest at 20.6 percent.4

DEFINITION

During 2019, the percent of women who reported experiencing 14 days or more of poor mental health in the past month.4

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Frequent Mental Distress

OKLAHOMA 15.6 percent

NATIONAL AVERAGE 13.8 percent

Why We Care: Women are nearly 30 percent more likely to report frequent mental distress than men.102 This is consistent with findings that women are twice as likely to develop major depressive disorder and general anxiety disorder than men, conditions which are both strongly associated with feelings of prolonged, persistent distress.102 Persistent feelings of mental distress are associated with stressful life events like divorce, job change or the death of a loved one.102 Additionally, individuals living in disinvested communities without access to adequate resources are more likely to experience frequent mental distress.102

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What We Can Do: - Work to improve social cohesion and support systems as supportive communities can provide a protective factor, increasing resilience in the face of stressful events - Work to improve telehealth and health communication technology so accessing counseling and non-emergency mental health services is easier and less expensive

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DEFINITION

The percent of women who have ever been told they have a depressive condition in 2019.4

Depression

OKLAHOMA 30.3 percent

NATIONAL AVERAGE 24.8 percent

Data Highlight: Across the nation, women are twice as likely as men to be diagnosed with a depressive disorder.4

Why We Care: While all people feel low moods from time to time, major depressive disorder is a mental health disorder that can severely impair a person’s ability to carry out activities of daily life.26 Women are twice as likely to be diagnosed with major depressive disorder than men.17,103 This inequity is linked to biological, social, and cultural factors that promote higher distress in women.17,104 While it is a common misconception that major depressive disorder is not a real illness, the data show that women living with this condition are at greater risk of developing heart disease, substance abuse issues, and are more likely to attempt suicide than those without this disorder.104,105

What We Can Do: - Work to de-stigmatize mental illness by educating yourself and others - Support organizations engaged in the implementation of Medicaid expansion

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Social Dynamics Support from significant others, family, and friends impact women’s health and well-being, acting as a protective factor in certain instances. Support systems can provide necessary encouragement to pursue further education, support in job changes, promotions, and other life events. Support from loved ones can help significantly when a woman is struggling with symptoms of depression or anxiety. 104 Support doesn’t only come from individuals, but can be felt in the culture and environment of municipalities and throughout the state through the creation of supportive or punitive policies. Oklahoma as a state falls short of the mark of providing beneficial support to its women. At a state level, when Oklahomans interact with the criminal justice system, women receive punitive punishments and are incarcerated at higher rates than men. The U.S. incarcerates the most people per capita than any other nation in the world, and Oklahoma incarcerates has the second-highest number of women, and third-highest number of men. To put this another way: Oklahoma has the secondhighest rate of female incarceration in the world.109,111 Women who are incarcerated have experienced some of the highest rates of abuse and trauma as children and adults. Incarceration compounds problems as those trapped in the justice system are exposed to further trauma and aren’t having any preexisting trauma, mental health, or physical health needs addressed.110 Among all populations of women, intimate partner violence and sexual violence are of grave concern in Oklahoma. In addition to the trauma survivors of intimate partner violence endure, survivors experience economic consequences of abuse.110,111

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There is silver living in this section, as Oklahoma has seen a groundswell of social action in the past few years, a sign that many are determined to improve the quality of life for women and all others. This is illustrated in the women who were voted into office in both our state and federal legislature. Oklahomans have also turned out to vote in record numbers since 2018,112 providing a glimmer of optimism that Oklahoma is making the turnaround that the women of the state deserve.

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DEFINITION

The lifetime prevalence of sexual violence classified as completed forced penetration, averaged from 2010-2012 data. 113

Sexual Violence

OKLAHOMA

Data Highlight: While Oklahoma ranks lower than the national average for NATIONAL AVERAGE 14.4 percent reported cases of overall sexual violence (all experience types leading up to forced penetration), it ranks highest in the nation 1 (of 51) for completed or attempted forced penetration. This might indicate low awareness among Oklahomans in the range of behaviors that are considered sexually violent that lead to forced penetration.113 18.7 percent

Why We Care: Compared to all other women, those who experience sexual violence are more likely to experience anxiety, depression, Post Traumatic Stress Disorder, self-harm, eating disorders, sleep disorder and suicide, among other health issues.114 society struggles to accept the evidence-based definitions of sexual violence, women often internalize experiences of sexual violence as a personal failing. Data recorded nationally for incidence of sexual violence was last conducted broadly in 2010-2012, which is less than ideal for active evaluation, and did not include adequate data on Indigenous, disabled, low-income, or LGBTQ+ populations.113,122 Through supplemental data collection efforts, all of these excluded groups reported a higher than average incidence of Sexual Violence .83 These data reported that 47 percent of transgender people report being sexually assaulted in their lifetime. Transgender people of color report even higher rates, with 67 percent of transgender indigenous people reporting being sexually assaulted in their lifetime. 122 What We Can Do: - Advocate for more frequent, more inclusive data collection that includes all forms of Sexual Violence and Intimate Partner Violence - Increase funding for Sexual Violence and Intimate Partner Violence programs across the state - Work to improve and increase wellness and healthy relationships curriculum for students - Work with law enforcement to ensure that cases of Sexual Violence and Intimate Partner Violence are being completed correctly Partner Violence are being completed correctly p. 68

Data Highlight: At a rate of 129, Oklahoma no longer has the highest rate of female incarceration in the world in 2019, overtaken by Idaho, with a rate of 138. Massachusetts remains the lowest, with a overall rate of just 10.111

DEFINITION

The number of women experiencing incarceration per every 100,000 women in 2019.109

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Female Incarceration

OKLAHOMA

129 per 100,000 women

NATIONAL AVERAGE 54 per 100,000 women

Why We Care: The United States leads the world in the number of its citizens it incarcerates.109,111 Prior to this year, the state of Oklahoma incarcerated the most men and women in the U.S. per capita, and consequently the world. While we may have overcome this sinister distinction, we still incarcerate the third highest rate of men, and second highest rate of women. 110,111 When Oklahoma women are incarcerated they are unable to work, access comprehensive health and mental health care, and are separated from their families which can be traumatizing for children. Many women within the justice system have experienced trauma in their lives, and incarceration exposes women to further trauma, rather than the trauma-informed care and social support they need.110,111

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What We Can Do: - Advocate for continued reforms, increased use of diversionary programs so women aren’t separated from their children, and improvements to the oversized and punitive penal code

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DEFINITION

“The Adverse Childhood Experiences (ACEs) are a measure of childhood trauma. The percentage of children ages 0-17 who experienced two or more of the following: economic hardship, parental divorce or separation, living with someone who had an alcohol or drug problem, neighborhood violence victim or witness, living with someone who was mentally ill, suicidal or severely depressed,domestic violence witness, parent served jail time, treated or judged unfairly due to race and ethnicity, or death of parent (2-year estimate between 2018-2010).”117

ACEs Reported Data Highlight: Justice involved women have some of the highest documented Adverse Childhood Experiences (ACEs) of any studied group,109,110 and justice involved youth are 13 times more likely to report at least one ACE measure than the general public.116

Why We Care: 19.8 percent Adverse Childhood Experiences (ACEs), are a measure of NATIONAL AVERAGE trauma and hardship experienced by an adult as a child. In 14.7 percent Oklahoma, over one in four adults experienced at least two adverse childhood experiences, increasing the likelihood with which that adult will struggle with health conditions like obesity, heart problems, or mental health issues.109,110,117 ACEs also increase the likelihood an adult will engage in smoking, alcohol, or substance use to self-medicate stress or past trauma. While many ACEs can be present at any socio-economic level, ACEs like divorce or having a parent incarcerated can create a strain on financial resources in families and disproportionately impact families of lower incomes.109,110 While ACEs do not factor in questions relating to race, ethnicity, ability, justice involvement, sexual orientation or gender identity, these factors absolutely contribute to variance in ACEs reported .117 OKLAHOMA

What We Can Do: - Bridge traditional health care with social service organizations and other community partners trained in evidence-based prevention programming, trauma-informed care - Remove barriers to access for mental health and substance abuse services - Support the creation of a clinical diagnostic tool modeled after the ACEs screening tool. - Ensure that health care providers are trained in trauma-informed Care in a clinical setting - Evaluate ACEs through the lens of identity (race, ethnicity, gender, gender expression, sexual orientation, etc.)

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Data Highlight: Oklahoma ranks 39 (of 50) for Intimate Partner Violence, which is linked to half of all female homicides nationwide .113

DEFINITION

The percentage of women 18 and older who experienced psychological, sexual, or physical violence, and/or stalking by an intimate partner. 113

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Intimate Partner Violence

OKLAHOMA 40.1 percent

NATIONAL AVERAGE 37.3 percent

Why We Care: One in three women have experienced intimate partner violence (IPV) in their lifetime, and can experience negative health outcomes for years after an occurrence. IPV includes psychological, physical and sexual components, and is characterized by the harm caused by a current or former partner. IPV is linked to over half of all female homicides, with a physical assault occurring one month before the incident.113,114 Though there are many different elements to IPV, most data and research only track the physical form.113 Black and Indigenous women are most likely to experience IPV, and poor data collection of Indigenous women has hampered awareness of this critical issue.83 The third-leading cause of death of Indigenous women is homicide, compared to the fifth-leading cause for all other women.113,115

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What We Can Do: - Advocate for more frequent, more inclusive data collection that include all forms of Sexual Violence and Intimate Partner Violence - Increase funding for Sexual Violence and Intimate Partner Violence programs across the state - Work to improve and increase wellness and healthy relationships curriculum for students - Work with law enforcement to ensure that cases of Sexual Violence and Intimate Partner Violence are being completed correctly

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DEFINITION

Percentage of female representation in state legislatures in 2019. 120

Political Representation

OKLAHOMA 21.5 percent

Data Highlight: Nationwide, female representation in state legislatures rose 28.9 percent from 25.4 to 28.9 percent from 2018-2019. In Oklahoma, that increase was more notable, increasing from 13.4 to 21.5 percent. This improved the state’s overall ranking, moving our position from 49th position in 2018, to 41st in 2019 .120 NATIONAL AVERAGE

Why We Care: Representation of women in public office is important to women’s health, as policy intervention is the most upstream solution to address poor health outcomes and disparities .120 Oklahoma has seen a groundswell of political action in the past few years, spurred both by national issues, as well as issues unique to Oklahoma. The 2018 Midterm election indicated that Oklahomans were ready for change, setting a 22 year record for voter participation, and a 60 percent increase in female representation in the state legislature.112,120,121 Having active female voice in the political process is essential to creating health policies that make sense for women and their families. What We Can Do: - Vote, and help others participate in the political process - Volunteer with organizations who support women running for public office - Support women from historically underrepresented or marginalized communities excel in political office

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Data Highlight: Oklahoma ranks 43 (of 51) in access to amenities. The state with the most access is Washington DC with 100 percent reporting access to at least one amenity, and Mississippi having the fewest amenities with 30.4 percent of children without access to a single public amenity.7

DEFINITION

The percent of children ages 0-17 with access to at least one amenity: park, playground, recreation center, c o m m u n i t y c e n t e r, b o y s’ a n d girls’ club, library, bookmobile, sidewalks or walking paths in 2019.7

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Amenities

OKLAHOMA 23.2 percent

NATIONAL AVERAGE 10.6 percent

Why We Care: Recreational amenities are a critical feature of cohesive communities that women are a part of. Places to commune such as libraries, playgrounds and community centers, and paved sidewalks facilitate socialization that makes living within a given community enjoyable.7,118,119 While the evidence is still forming, there are compelling arguments to be made that urban planning and design can contribute to the overall health and welfare of individuals. Apart from forming a sense of community and pride for one’s environment, having amenities nearby, especially parks, pools, or recreational facilities promote physical activity, which is well-documented to contribute to positive health outcomes.7,119

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What We Can Do: - Support and request the maintenance of existing parks and recreational areas, including sidewalks and ramps that make these areas accessible to women of all abilities

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Centers for Disease Control and Prevention. (2015, April). Vital Signs: Trends in use of long-acting reversible contraception among teens aged 15-19 years seeking contraceptive services – United States, 2005-2013 (Report No. 64(13);363369) (L. Romero, K. Pazol, L. Warner, L. Gavin, S. Moskosky, G. Besera,…W. Barfield, Authors). Retreived from CDC website. 2. Forman, C. (2019, August 11). Despite gains in 2018 elections, women still underrepresented at Oklahoma’s Capitol. Retrieved from The Oklahoman: https://oklahoman.com/article/5638355/despite-gains-in-2018-elections-women-still-underrepresented-at-oklahomas-capitol 3. United States Health and Human Services (US DHHS), Center for Disease Control (CDC). Behavioral Risk Factor Surveillance System Questionaire Web Enabled Analysis Tool. Public Use Data. https://nccd.cdc.gov/weat/#/crossTabulation/ 4. United States Department of Health and Human Services (US DHHS), Center for Disease Control. (2019). Behavioral Risk Factor Surveillance System Questionaire Web Enabled Analysis Tool. https://nccd.cdc.gov/weat/#/crossTabulation/ 5. Searing, A., & Cohen Ross, D. (May 2019). Medicaid expansion fills gaps in maternal health coverage leading to healthier mothers and babies [PDF file]. Retrieved from: https://ccf.georgetown.edu/ 6. 7.

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19. 20.

Fortier, J. (November 1, 2018). Oklahoma’s rural hospitals see a lifeline in Medicaid expansion. Retrieved from: https:// stateimpact.npr.org/oklahoma/ America’s Health Rankings analysis of U.S. HHS, HRSA, Maternal and Child Health Bureau (MCHB), Child and Adolescent Health Measurement Initiative (CAHMI), National Survey of Children’s Health Indicator Data Set, Data Resource Center for Child and Adolescent Health, United Health Foundation, AmericasHealthRankings.org, Accessed 2019. “United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Division of Vital Statistics, Natality public-use data 2018-2019, on CDC WONDER Online Database, September 2019. Accessed at http://wonder.cdc.gov/natality-expanded-current. html on Sep 30, 2019 3:33:31 PM “Center for Disease Control & Prevention. (2019). Weight gain during pregnancy. Retrieved from: https://www.cdc.gov/ reproductivehealth/maternalinfanthealth/ Katcher, M. (August 23, 2018). A Mother’s Zip Code Could Signal Whether Her Baby Will Be Born Too Early. Retrieved from The Atlantic: https://www.theatlantic.com/health/archive/2018/08/pre-term-birth-race/567862/ Aron, L., Bogle, M., Cohen, M., & Lipman, M. (2018, March). Prevention, Treatment, and Recovery: Toward a 10-Year Plan for Improving Mental Health and Wellness in Tulsa. Retrieved from The Urban Institute: Tulsa Mental Health. Turban, J. (2019, June 17). Ghost networks of psychiatrists make money for insurance companies but hinder patients’ access to care. Retrieved from Stat news. American Psychiatric Association. (2019) Mental Health Disparities: Diverse Populations. Retrieved from: https://www. psychiatry.org/ “US Census Bureau American Community Survey, B27001: Health Insurance Coverage Status By Sex By Age - Universe: Civilian noninstitutionalized population 2019 American Community Survey 1-Year Estimates” Buttorff C, Ruder T, Bauman M. Multiple Chronic Conditions in the United States pdf icon. Santa Monica, CA: Rand Corp.; 2017. “Center for Disease Control and Prevention. (2019, Febraury 11). Health and Economic Costs of Chronic Diseases. Retrieved from National Center for Chronic Disease and Health promotion: https://www.cdc.gov/chronicdisease/about/ costs/index.htm “Anxiety and Depression Association of America. (2010-2012). Girls and Women: Facts. Retrieved from: https://adaa. org/living-with-anxiety/women/facts Women’s College Hospital. (2018). Chronic Fatigue Syndrome. Retrieved from Women’s College Hospital: https://www. womenshealthmatters.ca/health-centres/environmental-health/chronic-fatigue-syndrome/ Behavioral Risk Factor Surveillance System Questionaire. 2019. https://nccd.cdc.gov/weat/#/crossTabulation/ Karpman, M., & Caswell, K. J. (March, 2017). Past-Due Medical Debt among Nonelderly Adults, 2012-2015. Retrieved from The Urban Institute Health Policy Center and Opportunity and Ownership Initiative: https://www.urban.org/sites/ default/files/publication/88586/past_due_medical_debt.pdf

26. America’s Health Rankings analysis of CDC, Behavioral Risk Factor Surveillance System, United Health Foundation, AmericasHealthRankings.org, Accessed 2019. 27. The Center for Disease Control and Prevention. (2018). Substance Use and Sexual Risk Behaviors Among Youth. Retrieced from: https://www.cdc.gov/healthyyouth/substance-use/pdf/dash-substance-use-fact-sheet.pdf 28. United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), Youth Risk Behavior Survey https://nccd.cdc.gov/Youthonline/App/ 29. GANDER, K. (2018, June 15). Why Are Teens Having Less Sex? Retrieved from Newsweek: https://www.newsweek. com/why-are-high-school-students-having-less-sex-979623 30. United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), Youth Risk Behavior Survey. 2019. https://nccd.cdc.gov/Youthonline/App/ 31. Secura GM, et al. “Provision of no-cost, long-acting contraception and teenage pregnancy”. The New England Journal of Medicine. 2014. 32. United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), Youth Risk Behavior Survey. 2019. https://nccd.cdc.gov/Youthonline/App/ 33. Brittney McNamara. (2017, June 26). Teens Report Using Pull Out Method As Birth Control. Retrieved from Teen Vogue: https://www.teenvogue.com/story/teens-report-pull-out-method-birth-control 34. United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), Youth Risk Behavior Survey https://nccd.cdc.gov/Youthonline/App/ 35. Biggs, S., and Griffin, A.J. (2016). House Bill 2398. [PDF File]. Retrieved from: http://webserver1.lsb.state.ok.us/ 36. Oklahoma State Department of Health. OK2SHARE: Vital Statistics 2019 (Preliminary Numbers) https://www.health. state.ok.us/stats/Vital_Statistics/Birth/Preliminary/Statistics_2010up.shtml 37. Kost K, et al U.S. Teenage pregnancies, births and abortions: National and state trends and trends by race and ethnicity. Guttmacher Institute 2010. 38. Rodine, S. (2019, August). Fast Facts. Retrieved from Healthy Teens Oklahoma: http://healthyteensok.org/fast-facts/ 39. America’s Health Rankings analysis of CDC WONDER Online Database, Underlying Cause of Death, Multiple Cause of Death files, United Health Foundation, AmericasHealthRankings.org, Accessed 2021. 40. Connley, C. (April 2, 2019). Reminder: Today isn’t Equal Pay Day for all women. Retrieved from: https://www.cnbc. com/2018/04/10/ 41. Institute for Women’s Policy Research. (2016). The Economic Impact of Equal Pay by State. Retrieved from: statusofwomendata.org/wp-content/uploads/2016/02/SWS-Equal-Pay-and-Poverty_final.pdf 42. “US Census Bureau American Community Survey, S1101: Percent females below poverty level ACS 1yr- Universe: Civilian noninstitutionalized population 2019 American Community Survey 1-Year Estimates” 43. Sonoma, S. (June 18, 2019). Black trans women want the media to show them living, not just dying. Retrieved from: https://www.vox.com/first-person/

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21. Michael Ollove. (2019, January 22). Here’s Why Rural Hospitals Are Shutting Down More Quickly In These States. Retrieved from The Huffington Post: https://www.huffpost.com/entry/rural-hospitals-close-medicaid-aca_b_5c4734d8e4b09dd3f0cb1f08 22. Kaiser Family Foundation. (March 13, 2018). Women’s coverage, access, and affordability: key findings from the 2017 Kaiser women’s health survey. Retrieved from: https://www.kff.org/womens-health-policy/ 23. United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Division of Vital Statistics, Mortality public-use data 2018-2019 , on CDC WONDER Online Database, September 2020. Accessed at http://wonder.cdc.gov/natality-expanded-current.html on Sep 30, 2019 3:33:31 PM 24. U.S. Department of Health and Human Services. (2020, January ). Oral health. Retrieved from Office of Women’s Health: https://www.womenshealth.gov/a-z-topics/oral-health 25. American College of Obstetricians and Gynecologists. (2013). Oral Health Care During Pregnancy and Through the Lifespan: Committee Opinion. Retrieved from American College of Obstetricians and Gynecologists: https://www.acog. org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/ Oral-Health-Care-During-Pregnancy-and-Through-the-Lifespan

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44. “US Census Bureau American Community Survey, S1101: Percent of female-headed households that received SNAP in the past 12 months- Universe: Civilian noninstitutionalized population 2019 American Community Survey 1-Year Estimates” 45. Food Research & Action Center, Remember This December: Hunger is Solvable With SNAP, https://frac.org/blog/remember-this-december-hunger-is-solvable-with-snap 46. Cullison, C. (May 8, 2019). Women still earn less than men, and it’s putting them at risk of living in poverty. (SNAP Narrative) Retrieved from: https://okpolicy.org/ 47. Food Research Action Network. (2018). Facts: SNAP Strengths. Retrieved From: frac.org/wp-content/uploads/fracfacts-snap-strengths.pdf 48. America’s Health Rankings analysis of U.S. Census Bureau, American Community Survey, United Health Foundation, AmericasHealthRankings.org, Accessed 2021 49. Food Research and Action Center, “The Impact of Food Insecurity on Women’s Health,” Retrieved from: https://www. frac.org/blog/impact-food-insecurity-womens-health 50. Feeding America, Hunger and Health “What is Food Insecurity in America?,” Retrieved from: https://hungerandhealth. feedingamerica.org/understand-food-insecurity/

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51. “Us Census Bureau American Community Survey, S1101: Households And Families 2019 American Community Survey 1-Year Estimates” 52. National Partnership for Women and Families. (2020, September). America’s Women and the Wage Gap. Retrieved from National Partnership for Women and Families: http://www.nationalpartnership.org/our-work/resources/economic-justice/fair-pay/americas-women-and-the-wage-gap.pdf 53. “Heidi Hartmann, P., & Ariane Hegewisch, M. (2019, March 7). The Gender Wage Gap: 2019 Earnings Differences by Race and Ethnicity. Retrieved from The Institute for Women’s Policy Research: https://iwpr.org/publications/genderwage-gap-2018/ 54. America’s Health Rankings analysis of Child Care Aware, Cost of Child Care Report, United Health Foundation, AmericasHealthRankings.org, Accessed 2019. 55. America’s Health Rankings analysis of U.S. Department of Housing and Urban Development, Comprehensive Housing Affordability Strategy (CHAS), United Health Foundation, AmericasHealthRankings.org, Accessed 2021. 56. National Association of Counties. (2017) Housing for the justice-involved: a case for county action. [PDF File]. Retrieved from: http://johnjaypri.org/ 57. Human Rights Campaign. (2019) Housing for LGBTQ People: What You Need to Know About Property Ownership and Discrimination. Retrieved from: https://www.hrc.org/resources/ 58. Hinchey, K. (September 24, 2019). Black, Latino children more likely to live in concentrated poverty than white children, report finds. Retreived from: https://www.tulsaworld.com/ 59. Libassi, C. (May 23, 2018). The neglected college race gap: racial disparities among college completers [PDF file]. Retrieved from: https://cdn.americanprogress.org/ 60. “U.S. Census Bureau, 2017 American Community Survey, B15002: Sex By Educational Attainment For The Population 25 YEARS AND OVER - Universe: Population 25 years and over. 2017 American Community Survey 1-Year Estimates” 61. DuMonthier, A., Childers, C., and Milli, J. (2019). The status of Black women in the United States. (PDF File). Retrieved from: https://www.domesticworkers.org/ 62. Fry, R. (May 14, 2014). Young adults, student debt and economic well-being. Retrieved from: https://www.pewsocialtrends.org/ 63. Rossie Barroso, A., & Patrick, K. (October 6, 2017). What can a degree do for you? A lot less, if you’re a woman. Retrieved from: https://nwlc.org/blog/ 64. “U.S. Census Bureau, 2019 American Community Survey, B15002: Sex By Educational Attainment For The Population 25 Years And Over - Universe: Population 25 Years And Over. 2017 American Community Survey 1-Year Estimates” 65. McFarland, J., Cui, J., Rathbun, A., & Holmes, J. (2019). Trends in High School Dropout Rates in the United States: 2018. Retrieved from US Department of Education, National Center for Education Statistics, Institute of Edcuation Sciences: https://nces.ed.gov/pubs2019/2019117.pdf 66. National Women’s Law Center. (2007, October 30). High School Dropouts: A Problem for Girls and Boys. Retrieved from National Women’s Law Center: https://nwlc.org/press-releases/high-school-dropouts-problem-girls-and-boys/

Disease Control and Prevention: https://www.cdc.gov/teenpregnancy/about/index.htm 74. Oklahoma Healthcare Authority. (2021). SoonerCare and Insure Oklahoma Income Guidelines. Retrieved from Oklahoma Healthcare Authority: https://www.okhca.org/individuals.aspx?id=10328 75. Fetters, A. (2018, August 10). The Doctor Doesn’t Listen to Her. But the Media Is Starting To. Retrieved from The Atlantic: https://www.theatlantic.com/family/archive/2018/08/womens-health-care-gaslighting/567149/ 76. Hoffmann, D. E., & Tarzian, A. J. (2002). The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain. Journal of Law, Medicine & Ethics. 77. Oxford Dictionaries, s.v. “Gaslight,” accessed January 13, 2019, https://en.oxforddictionaries.com/definition/gaslight 78. Martin, N., & Montagne, R. (2017, December 7). Black Mothers Keep Dying After Giving Birth. Shalon Irving’s Story Explains Why. Retrieved from National Public Radio (NPR) : https://www.npr.org/2017/12/07/568948782/black-mothers-keep-dying-after-giving-birth-shalon-irvings-story-explains-why 79. Stallings, E. (August 1, 2018). This is how the american healthcare system is failing black women. Retrieved from: https:// www.oprahmag.com/life/health/a23100351/racial-bias-in-healthcare-black-women/ 80. Truth Initiative. (2019, April). Tobacco use in Oklahoma 2019. Retrieved from Truth Initiative: https://truthinitiative.org/ research-resources/smoking-region/tobacco-use-oklahoma-2019 81. U.S. Department of Health and Human Services, N. C. (n.d.). Smoking & Your Baby. Retrieved from SmokeFree.Gov: https://women.smokefree.gov/pregnancy-motherhood/quitting-while-pregnant/smoking-your-baby 82. SmokeFreeWomen, “How Quitting Helps Women’s Health,” Retrieved from: https://women.smokefree.gov/quit-smoking-women/what-women-should-know/how-quitting-helps-women 83. Schwabish, J., & Anderson, N. (2019). How much we know about intimiate partner violence across racial and ethnic groups. Retrieved from: http://apps.urban.org/features/domestic-violence-data/ 84. U.S. Department of Health & Human Services, Center for Disease Control. (2019). Obesity in Adults. Retrieved from Center for Disease Control: https://www.cdc.gov/obesity/adult/causes.html 85. America’s Health Rankings analysis of CDC, Behavioral Risk Factor Surveillance System, United Health Foundation, AmericasHealthRankings.org, Accessed 20212021. 86. Armstrong, B. (2018, December 26). How Excercise Affects Your Brain. Retrieved from Scientific American: https:// www.scientificamerican.com/article/how-exercise-affects-your-brain/ 87. Meghan Baruth, P., Patricia A. Sharpe, P. M., Deborah Parra-Medina, P. M., & Sara Wilcox, P. (2015). Perceived barriers to exercise and healthy eating among women from disadvantaged neighborhoods: Results from a focus groups assessment. Women Health. 88. Koller-Smith, L., Shah, P., Ye, X., et al. (July 14, 2017). Comparing very low birth weight versus very low gestation cohort methods for outcome analysis of high risk preterm infants. BMC Pediatrics, 166. Retrieved from: https://bmcpediatr. biomedcentral.com/articles/ 89. March of Dimes. (2020). Premature birth report cards. Retrieved from: https://www.marchofdimes.org/mission/prematurity-reportcard.aspx

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67. U.S. Department of Education, National Center for Education Statistics. Data Lab Web Tool. Public-use Data. https:// nces.ed.gov/datalab/index.aspx 68. Virginia Commonwealth University. (2015, February 13). Why Education Matters to Health: Exploring the Causes. Retrieved from Virginia Commonwealth University: https://societyhealth.vcu.edu/work/the-projects/why-education-matters-to-health-exploring-the-causes.html 69. Chalk.com; data via U.S. Department of Education, National Center for Education Statistics 70. Association of Maternal & Child Health Programs. (Summer 2014). Life Course Indicator: Repeat Teen Birth [PDF file]. Retrieved from: http://www.amchp.org/programsandtopics/data-assessment/ 71. Oklahoma State Health Department. (August 2018). Rapid repeat births among Oklahoma teens [PDF file]. Retrieved from: https://www.ok.gov/ 72. U.S. Department of Health & Human Services, Office of Adolescent Health. (2017, February 13). Pregnancy Assistance Fund (PAF). Retrieved from U.S. Department of Health & Human Services: https://www.hhs.gov/ash/oah/grant-programs/pregnancy-assistance-fund/index.html 73. U.S. Department of Health & Human Services, Center for Disease Control and Prevention. (2019, September 9). Reproductive Health: About Teen Pregnancy. Retrieved from U.S. Department of Health & Human Services, Center for

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90. March Of Dimes. March, 2018. “Preterm Labor And Premature Birth: Are You At Risk?” Retrieved from: https://www. marchofdimes.org/complications/preterm-labor-and-premature-birth-are-you-at-risk.aspx 91. SmokeFreeWomen, “How Quitting Helps Women’s Health,” Retrieved from: https://women.smokefree.gov/quit-smoking-women/what-women-should-know/how-quitting-helps-women 92. March of Dimes. (2020) Neonatal Death. Retrieved from: https://www.marchofdimes.org/complications/ 93. Acog Green Journal: Racial and Ethnic Disparities in the Incidence of Severe Maternal Morbidity in the US, 2012–2015. (2018, October 22). Retrieved from Oklahoma Perinatal Quality Improvement Collaborative: https://opqic.org/ acog-green-journal-racial-and-ethnic-disparities-in-the-incidence-of-severe-maternal-morbidity-in-the-unitedstates-2012-2015/ 94. Den Harder, M. (September 17, 2019). Want healthier moms? Expand Medicaid. Retrieved from: https://okpolicy.org/ 95. AJOG: A Comorbidity-Based Screening Tool to Predict Severe Maternal Morbidity at the Time of Delivery. (2019, August 2). Retrieved from Oklahoma Perinatal Quality Improvement Collaborative: https://opqic.org/ajog-a-comorbidity-based-screening-tool-to-predict-severe-maternal-morbidity-at-the-time-of-delivery/ 96. America’s Health Rankings analysis of CDC and States, Pregnancy Risk Assessment Monitoring System or equivalent, United Health Foundation, AmericasHealthRankings.org, Accessed 2021.

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97. American Journal of Obstetrics and Gynecology. Paschetta et al, “Perinatal psychiatric disorders: an overview” 98. Bice, S., & Miller, N. (2019). Sentate Bill 419 [PDF file]. Retrieved from: http://webserver1.lsb.state.ok.us/ 99. Center for Disease Control and Prevention: Consumption of Alcohol Beverages and Binge Drinking Among Pregnant Women Aged 18–44 Years — United States, 2015–2011. 100. National Institute on Alcohol Abuse and Alcoholism. (2019, June). Women and Alcohol. Retrieved from National Institute on Alcohol Abuse and Alcoholism: https://www.niaaa.nih.gov/sites/default/files/publications/WomenAlcohol_Factsheet_v31_Release_0.pdf 101. “An Invariant Dimensional Liability Model of Gender Differences in Mental Disorder Prevalence: Evidence from a National Sample,” Nicholas R. Eaton, MA, and Robert. F. Krueger, PhD, University of Minnesota; Katherine M. Keyes, PhD, and Deborah S. Hasin, PhD, Columbia University; Steve Balsis, PhD, Texas A&M University; Andrew E. Skodol, MD, Columbia University and University of Arizona; Kristian E. Markon, PhD, University of Iowa; Bridget F. Grant, PhD, National Institute on Alcohol Abuse and Alcoholism; Journal of Abnormal Psychology, Vol. 121, No. 1. 102. America’s Health Rankings analysis of CDC, Behavioral Risk Factor Surveillance System, United Health Foundation, AmericasHealthRankings.org, Accessed 2021. 103. National Institute of Mental Health. (2019, February). Major Depression. Retrieved from National Institute of Mental Health: https://www.nimh.nih.gov/health/statistics/major-depression.shtml 104. Office on Women’s Health. (2019). Depression. Retrieved from: https://www.womenshealth.gov/mental-health/mental-health-conditions/depression 105. Sandoiu, A. (March 19, 2019). Heart disease and depression: Scientists find missing link. Retrieved from: https://www. medicalnewstoday.com/articles/324748.php 106. Kaiser Family Foundatin. (2019). Opioid Overdose Deaths by Gender, 2017. Retrieved from Kaiser Family Foundatin: https://www.kff.org/other/state-indicator/opioid-overdose-deaths-by-gender/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D 107. National Institute on Drug Abuse. (2018). Common Comorbidities with Substance Use Disorders. Retrieved from: https://www.drugabuse.gov/publications/ 108. National Institute on Mental Health. (2019). Substance Use and Mental Health. Retrieved from: https://www.nimh.nih. gov/health/topics/substance-use-and-mental-health/ 109. “Bureau of Justice Statistics. (2017). Data Collection: National Prisoner Statistics (NPS) Program. https://www.bjs.gov/ index.cfm?ty=dcdetail&iid=269” 110. Cook, J. (2018, December 6). Past Trauma Causes Many Women to Wind up in Jail. Retrieved from The Hill: https://thehill.com/opinion/criminal-justice/420068-past-trauma-causes-many-women-to-wind-up-in-jail 111. Gentzler, R. (2019, May 2). Accepting Our Highest-in-the-World Incarceration Rate Means Believing that Oklahomans are the Worst People. Retrieved from Oklahoma Policy Institute.

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112. KFor-TV. (November 7, 2018). Officials: Oklahoma’s midterm voter turnout sets new 22-year high. Retrieved from: https://kfor.com/2018/11/07/officials-oklahomas-midterm-voter-turnout-sets-new-22-year-high/ 113. Smith, S.G., Chen, J., & Basile, K.C., et al. (April 2017). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010-2012 State Report 114. RAINN (Rape, A. &. (2019). Effects of Sexual Violence. Retrieved from RAINN: https://www.rainn.org/effects-sexual-violence 115. Echo-Hawk, A., Lucchesi, A.. (2018). Urban Indian Health Institute. Missing and Murdered Indigenous Women. Seattle Indian Health Board. Retrieved from: https://www.uihi.org/wp-content/uploads/2018/11/Missing-and-Murdered-Indigenous-Women-and-Girls-Report.pdf 116. Center for Health and Justice. (2014). High Rates of Adverse Childhood Experiences Among Justice-Involved Youth Increase Risk for Health, Social Problems. Facts on Youth: Issue 3. Retrieved from: www2.centerforhealthandjustice.org/ sites/www2.centerforhealthandjustice.org/files/publications/FOY%2008-14_Issue3.pdf 117. America’s Health Rankings analysis of U.S. HHS, HRSA, Maternal and Child Health Bureau (MCHB), Child and Adolescent Health Measurement Initiative (CAHMI), National Survey of Children’s Health Indicator Data Set, Data Resource Center for Child and Adolescent Health, United Health Foundation, AmericasHealthRankings.org, Accessed 2021.

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118. Aysola, J., Orav, E. J., & Ayanian, J. Z. (2011). Neighborhood Characteristics Associated With Access To Patient-Centered Medical Homes For Children. Health Centers & Health Homes, 2080-2089. Retrieved from https://www. healthaffairs.org/doi/pdf/10.1377/hlthaff.2011.0656 119. Teresa Mozur. (2016, August 22). 6 Reasons Why Parks Matter for Health. Retrieved from Robert Wood Johnson Foundation: https://www.rwjf.org/en/blog/2016/08/6_reasons_why_parks.html 120. National Conference of State Legislatures. (2019). Women in state legislatures for 2019. Retrieved from: http://www. ncsl.org/ 121. Hartig, H. (May 3, 2019). In year of record midterm turnout, women continued to vote at higher rates than men. Retrieved from: https://www.pewresearch.org/fact-tank/ 122. The Human Rights Campaign. (2019). Sexual Assault and the LGBTQ Community. Retrieved from The Human Rights Campaign: https://www.hrc.org/resources/sexual-assault-and-the-lgbt-community 123. Oklahoma State Department of Health. (n.d.). Frequently Asked Questions. Retrieved January 8, 2021, from https:// oklahoma.gov/health/family-health/breastfeeding/frequently-asked-questions.html#why 124. Baby-Friendly USA. (n.d.). About. https://www.babyfriendlyusa.org/about/ 125. Oklahoma Breastfeeding Resource Center. (n.d.). What is Baby Friendly? 2021. https://obrc.ouhsc.edu/Baby-Friendly-Hospitals 126. Centers for Disease Control and Prevention. (n.d.). Rates of Any and Exclusive Breastfeeding by State Among Children Born in 2017 (Percentage +/- half 95% Confidence Interval). 127. American College of Obstetricians and Gynecologists. (2019, August). Breastfeeding Your Baby. 128. Centers of Disease Control and Prevention. (2020, May 28). Breastfeeding FAQs. 129. World Health Organization. (2019, November 11). Breastfeeding. 130. Mannel, R., & Bacon, N. (2013, January 24). Oklahoma’s Breastfeeding Activities and Hotline: Positive Steps to Reducing Infant Mortality [Slides]. Association of Maternal & Child Health Programs. 131. Oklahoma State Department of Health. (n.d.). Frequently Asked Questions. https://oklahoma.gov/health/family-health/ breastfeeding/frequently-asked-questions.html#why 132. U.S. Breastfeeding Committee. (n.d.). USBC : Breastfeeding Savings Calculator. Retrieved January 8, 2021, from http:// www.usbreastfeeding.org/p/cm/ld/fid=439 133. U.S. Department of HHS, Centers for Disease Control and Prevention (CDC), National Vital Statistics System (NVSS), “Births: Provisional Data for 2019” (May 2020) https://www.cdc.gov/nchs/data/vsrr/vsrr-8-508.pdf

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ACKN OWL E DGE M E N T S There are many people we are grateful for and we want to take a moment to highlight just a few of those who helped with the composition of this Data Lookbook. A big thank you to the many community members who helped provide references, sources, and feedback throughout the writing and creative process. Metriarch Collaborative: Without all of you, this Lookbook wouldn’t serve the same purpose! Thank you for the work you all do, day in and day out at your various organizations across Oklahoma. Special shout out to Becky Mannel, MPH, IBCLC, FILCA, of the Oklahoma Breastfeeding Resource Center, for supporting the 2021 addition of breastfeeding-related indicators. Monica Musgrave, Tulsa Public School teacher and community advocate: Thank you for fighting for our community and providing a message that sets the tone for the Data Lookbook. Thank you to our Lookbook Volume 2 editors: Sharayah Fore, MA, Senior Director of Data and Evaluation; Thrive OKC Melanie Poulter, MA, Director of Innovation, Data & Research; Census Information Center of Eastern Oklahoma Director; Equality Indicators Project Manager at Community Service Council Maggie Shaffer-den Harder, MPA Thank you to all of Take Control Initiative staff for incubating Metriarch with special thanks to the following people for thier contributions to LookBook Volume 2: Paola Almanza, Digital and Creative Coordinator Rachel Armstrong, Metriarch Fellow Laura Bellis, Executive Director Jenna Chapman, Women’s Health Policy Manager Mindy Galoob, Deputy Director Sujeiry Jimenez, Community Advocacy Fellow Emma Swepston, MPA, Data and Policy Director Tommy Yap, MPA, Policy and Research Coordinator

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Massive thank you to the public and private entities that work tirelessly to track, collect and analyze these data for public use. The work you do has an everlasting impact.

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“What keeps you up at night? Is it racism, climate crisis, kids in cages, patriarchy, poverty, preventable pandemics? We do not have to accept the status quo. We can do better on behalf of each other. We can achieve the greatest good for the greatest number of people. And together, I am certain we will successfully diagnose the pathogens of yesterday and today. And the tomorrow that we build will be healthier, more equitable, and more just.”

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— Mona Hanna-Attisha, MD, MPH, Founder and Director, Michigan State University and Hurley Children’s Hospital Pediatric Public Health Initiative

Metriarch is a statewide data collaborative that aims to normalize and broaden women’s health conversations in Oklahoma through data storytelling, resource curation, and interactive outreach events.

Data LookBook Vol. 2

Articles inside

Amenities

ACEs Reported

Intimate Partner Violence

Female Incarceration

Frequent Mental Distress

Drug-Related Deaths

Binge Drinking

Sexual Violence

Postpartum Depression

Neonatal Death

Maternal Mortality

Preterm Births

Healthy Birth Spacing

Obesity

Low Birthweight

Poor Health Perceptions

Women Who Smoke

Subsequent Teen Births

Women with a College Degree

Substandard Housing

Cost of Child Care

High School Drop-Out Rate

Teen Birth Rate

Gender Pay Gap

Food Insecurity

Women Experiencing Poverty

Consistent Primary Care

Teen Condom Usage

Adequate Prenatal Care

Access to Dental Care

Access to Mental Health Services

Teen Sexual Activity

Drug or Alcohol ...of Teens

Uninsured Women