About one in four Americans has one or more forms of cardiovascular disease (CVD) (e.g., high blood pressure, coronary heart disease, stroke, congenital defects, and rheumatic heart disease). CVD accounts for about 35.3% of all deaths in the United States, or about one out of every 2.8 deaths. One in ten women under age 60 years has some form of CVD; the ratio increases to one in three after age 65 years. Black women are more likely to die of CVDs than white women. In 2005, the CVD death rate among white females was 230.4 per 100,000, compared with 319.7 per 100,000 for black females. Black women are also more likely to die of stroke than white women (60.7 per 100,000 and 44 per 100,000, respectively) (American Heart Association [AHA], 2009a).

Cardiovascular disease continues to be the number one overall killer of women. One out of every 2.4 deaths is from CVD, whereas one out of every 29 deaths is from breast cancer. In 2007, CVD caused more deaths among females (454,613, or 36.7%) than among males (409,867, or 34.2%) (AHA, 2009a). The overall number of deaths due to CVD decreased dramatically from 424.2 per 100,000 in 1950 to 273 per 100,000 in 2003.

Nevertheless, disparities continue related to prevention, diagnosis, and management of heart disease in women. After the age of 65 years, women are twice as likely to die because of heart disease as men (Vaccarino et al., 2003; American Heart Association, 2009b). Women have higher rates of complications after revascularization procedures (Jacobs, 2003) and higher rates of death after myocardial infarction (Wenger, 2004). This phenomenon exists because women display different symptoms of heart disease and are managed differently than men (Chang et al., 2003; Martin et al., 2004; Schulman et al., 1999). Physiologically, women have smaller arteries and higher rates of metabolic syndrome, diabetes, heart failure, and other comorbidities. They tend to be older at their first cardiovascular event, with more urgent and emergent presentations (Jacobs, 2003). These differences result in fewer preventative interventions, such as cholesterol screening, use of aspirin and other fibrinolytic therapy, and statin drugs to lower cholesterol (Downs, Clearfield, and Weis, 1998).

Rates of CVD among women can decline further when individuals become more aware of risk factors and accept responsibility for managing their own health and well-being (Kuehn, McMahon, and Creekmore, 1999). Concerned and motivated providers must encourage women to practice heart-healthy behaviors. In 2002, the American Heart Association launched the “Go Red” campaign for women and “The Heart Truth” program for health care providers designed to educate both about the unique features of women and heart disease.

Cancer is the second leading cause of death in the United States. Of deaths in America in 2008, 23% were due to cancer. (American Cancer Society [ACS], 2009). Further, cancer is expected to become the overall leading cause of death in the next decade (Stewart, King, Thompson, Friedman, Wingo, 2004).

Cancer rates appear to be increasing for a number of reasons including lifestyle choices (smoking, diet, sun exposure), increasing exposure to environmental carcinogens, and, probably most important, age. To illustrate, death rates from cancer among women have increased from 136 per 100,000 women in 1960 to 167.3 per 100,000 women in 2000 (Stewart, et al., 2004). The ACS estimates that 296,000 deaths will occur among women as a result of cancer in 2009 (ACS, 2008).

In 1987, lung cancer surpassed breast cancer as the leading cause of cancer deaths in women, and death rates increased sharply until about 1990. Lung cancer deaths leveled off, and in 2005 26% of cancer deaths in American women were attributed to lung cancer. Breast cancer was the second most common cause and resulted in 15% of all cancer deaths (ACS, 2008). Colorectal cancer, the third most frequent cause of cancer deaths, accounts for 9% of all cancer deaths and claims the lives of some 28,000 women annually.

Other female-specific cancers include ovarian cancer (fifth most common cancer), uterine cancer (sixth most common cancer), and cervical cancer. Cervical cancer, in particular, has received considerable attention of late as it has been determined that 90% of women with cervical cancer have evidence of cervical infection with human papillomavirus (HPV) (ACS, 2009). In June 2006, the Food and Drug Administration (FDA) licensed Gardasil (Merck & Co., Inc.), the first vaccine to prevent HPV infection (CDC, 2007b; FDA, 2006). Since approval, more than 7 million doses have been given (CDC, 2007b). Gardasil has been shown to be highly effective in preventing the most common types of HPV infection and was approved for use in females between 9 and 26 years of age. For additional information consult the CDC’s website (www.cdc.gov/vaccinesafety/Vaccines/HPV/gardasil.html).

The good news is that healthy lifestyle changes and early detection and intervention have contributed to the decrease in mortality rates from some cancers. For example, the death rate for colorectal cancer has been decreasing for the past 15 years because of early detection and treatment. Lung cancer deaths are beginning to show a slight decline that parallels a decreased incidence of smoking by women over the age of 18 years (ACS, 2009).

Five-year survival rates vary according to the type of cancer and stage at diagnosis. For instance, the 5-year survival rate for all clients with lung cancer is only 18%. For localized breast cancer, it is 98%, decreasing to 23% when diagnosed with distant metastases. Of cancers related to the reproductive tract, ovarian cancer has the lowest survival rate, as only around 46% of women survive for 5 years. When the cancer is diagnosed at an early stage, 5-year survival rate for women with colon cancer is 91% and for those with rectal cancer it is 89% (National Cancer Institute, 2009).

Early diagnosis and prompt treatment are major factors in surviving many types of cancer. According to the ACS (2008) this includes routine cervical cancer screening with Pap smear and HPV tests beginning 3 years after the onset of intercourse, and continuing annually. After age 30 years, women with three negative annual Pap tests can be screened every 3 years. Breast cancer screenings include regular self breast examination and annual clinical breast exam, with the addition of a mammogram after the age of 40 years or sooner with increased risk of hereditary breast cancer. Colorectal cancer screenings include annual fecal occult blood tests along with sigmoidoscopy every 5 years or colonoscopy every 10 years (ACS, 2008).

Certain health choices may reduce an individual’s risk of cancer. All women need to avoid health-deteriorating practices and replace them with health-promoting behaviors. Women could reduce their risk for cancer by never smoking or by quitting if they already use tobacco products. Eating a nutritious, plant-focused, high-fiber diet, along with adopting a physically active lifestyle and maintaining a healthy body weight, protect against both heart disease and many cancers. Nutrition guidelines include avoiding salt-cured, smoked, nitrite-containing, and charred foods, high-fat food, and excessive alcohol (Rhodes, 2002; Vogel, 2003). Obesity has been associated with an increased risk for cancers such as colon and rectum, endometrium, and breast (ACS, 2008). Finally, the practice of safe sex has been shown to decrease the spread of cancer associated with sexually transmitted diseases such as HPV, hepatitis B and C, and human immunodeficiency virus (HIV).

Community health nurses must encourage all females (i.e., from childhood to old age) to adopt these healthy lifestyle choices and pursue early cancer detection. Community health nurses play a major role in providing cancer control services that should be culturally sensitive and appropriate to the targeted aggregate. If providers and clients applied everything known about cancer prevention, approximately two thirds of cancer cases would not occur.

In 2008, the number of patients with diabetes in the United States reached 24 million, or 8% of the population, with 25% of the population over 60 years of age being affected (CDC, 2008e). From 2003 to 2006, the number of patients with diagnosed diabetes had risen by 7.8%, especially among women (Cheung, Ong, and Cherny, 2009), although the number of men affected has exceeded women since 2006 (CDC, 2009a).

Diabetes mellitus is a chronic disease that causes premature death of many women and overall ranks sixth in mortality among that group, highest after the age of 45 years (CDC, 2007c). Diabetes ranks fourth as the cause of death among several aggregates, including Native American, black, and Asian, and is fifth among Hispanics (National Center for Health Statistics, 2004).

In addition to being a serious illness in itself, diabetes is a risk factor for the development of CVD; furthermore, it dramatically influences the severity and course of the CVD. In death certificates from 2004 where the cause of death was related to diabetes, 68% also listed CVD and 16% also listed stroke (CDC, 2008e). When comparing men and women with diabetes, of those who have myocardial infarction before age 65 years, women are more likely to have long-term health problems and to die (Norhammar et al., 2008). The good news is that the number of women hospitalized for diabetes has dropped, indicating that better management with tighter control of blood glucose has decreased complications (CDC, 2008c). The community health nurse is an important resource for supporting the tight control of diabetes to prevent its complications. An upstream approach to this problem includes helping women maintain a desirable weight throughout life in an effort to avoid nutrition-related causes of death, such as diabetes and CVD.

According to the Safe Motherhood Organization (2005), complications of pregnancy and childbirth are the leading cause of disability and death among women between the ages of 14 and 49 years. In 2005, 536,000 women died, mostly in developing countries. Forty percent of women have complications during pregnancy, childbirth, and the postpartum period; 15% are life-threatening problems.

Before 2003, maternal mortality was the death of a woman while pregnant or within 42 days after termination of pregnancy. The U.S. Standard Certificate of Death and the WHO’s ICD-10 revised those guidelines in 2003 to include late causes of maternal death, defined as greater than 42 days but less than 1 year after the end of the pregnancy (Hoyert, 2007; WHO, 2007). The duration and the site of the pregnancy are irrelevant; causes are defined as related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

It is important for community health nurses to be aware of the global situation surrounding maternal mortality. For each woman who dies in the developed world, 99 will die in the developing world (WHO, 2000), demonstrating that wide gaps continue to exist in the availability and quality of reproductive health care services globally.

The United States ranks seventeenth in maternal mortality among all nations. In 2005 the rate of maternal death was 12.1 per 100,000 pregnancies (Department of Reproductive Health and Research, 2005). Reduction of maternal mortality is one of the Healthy People 2020 objectives for the United States.

Beginning in the 1950s, maternal mortality rates began to decline in the United States because of the use of blood transfusions, antimicrobial drugs, and the maintenance of fluid and electrolyte balance during serious complications of pregnancy and birth. The development of obstetric training programs and obstetric anesthesia programs was also important.

Racial discrepancy persists, however, in maternal mortality rates as in life expectancy. Table 17-2 illustrates how nonwhite women have a significantly higher incidence of death during pregnancy than whites. The gap in maternal mortality rates between black and white women has widened over the past several decades. Early in the twentieth century, black women were two times more likely to die of pregnancy-related complications than white women. Currently, black women are nearly four times more likely to die than white women (CDC, 2007c). Major risk factors for maternal death include lack of antepartal care and family planning services, inadequate health education, and poor nutrition. An additional risk factor, regardless of race, is advancing age. Women aged 40 years and older have over three times the risk of dying of a pregnancy-related cause as women aged 30 to 39 years (National Center for Health Statistics, 2007). Intrinsic maternal factors, such as increasing frequency of hypertension and a greater likelihood of uterine hemorrhage, help explain this increase in the mortality rate among older mothers.

In 2005, maternal mortality was 15.1 per 100,000 live births, up from 12 per 100,000 in 2003 in the United States. Historically, the leading cause of maternal death is pulmonary embolism (17%), followed by pregnancy-induced hypertension, ectopic pregnancy, hemorrhage, stroke, and anesthesia (Cunningham et al., 2005). Of growing concern is the increasing cesarean section rate, incidence of maternal obesity, and increased age of mothers, which may be contributing to the rise in this rate (Kaiser, 2007). Death associated with legal surgical abortion is rare in the United States, with 33 reported in 2005 (Kung et al., 2008). Complications that result in death from legal abortion relate to the woman’s age, the type of procedure, the gestational age of the fetus, and general health problems at the time of the abortion (Cates, Ellertson, and Stewart, 2004).

A medical, or induced, method of abortion using mifepristone (i.e., RU-486), an antiprogestin medication, together with prostaglandins has been used in the United States since September 2000. This method is as effective as surgical abortion and is considered a safe alternative to surgical abortion in pregnancies of less than 49 days (7 weeks). In 2005, 9.9% of the 820,151 legal abortions in the United States employed this method. Curettage as an abortion procedure is still the most widely used (Gamble et al., 2008).

Abortion is a controversial issue for providers and for the women in their care. Adequate access to affordable family planning services is key to decreasing the need for elective abortions. Consider this quote from Dr. Joycelyn Elders: “I never knew a woman who needed an abortion who wasn’t already pregnant” (Elders, 2009). Nurses must continue to keep abreast of all available pregnancy prevention and termination options to provide the best counsel for women.

According to the CDC (2003), ectopic pregnancy is the leading cause of maternal death in the first trimester, accounting for 13% of maternal deaths. Since the 1980s, the incidence of ectopic pregnancy has increased fourfold to 11.3 per 1000 pregnancies among women 15 to 44 years of age. Racial discrepancy is evident and yields a rate of 14.7 per 1000 among nonwhites compared with 10.3 per 1000 among whites. This disparity continues to increase throughout the reproductive years of nonwhite women, possibly because sexually transmitted diseases (STDs) are more frequently diagnosed among nonwhite women, and these clients have less access to health care.

The most significant risk for ectopic pregnancy is previous pelvic inflammatory disease (PID) or salpingitis. Early diagnosis and treatment greatly reduce the mortality rate. Prevention interventions for women at risk for acquiring STDs are critical in reducing a woman’s risk for an ectopic pregnancy. An important task of health care providers is to educate women and men on methods to reduce sexual health risk-taking behaviors. Additional risk factors for ectopic pregnancy include tubal pathology, previous ectopic pregnancy, tubal surgery, and the use of intrauterine contraceptive devices.

The 2008 National Hospital Discharge Survey (CDC) reported that more women than men are hospitalized each year in the United States. Pneumonia resulted in an average hospital stay of 5.6 days, which occurred most frequently among women aged 65 years or older. Fractures accounted for an average of 5.8 days, malignant neoplasms for an average 6.7 days, and diseases of the heart for an average 4.7 days. The number one reason for hospitalization was childbirth, followed by circulatory, digestive, respiratory diseases, and finally injury or poisoning. The length of hospitalization after childbirth has increased along with the C-section rate since 1995 (DeFrances et al., 2006).

The prospective payment system for hospitalization resulted in an increased demand for skilled nursing services in the home. After hospitalization for several of these conditions, community health nurses may provide ongoing nursing care in the home by referral. Nurses practicing in home environments must be prepared to deliver high-tech and high-touch services. Chapter 33 discusses home health care in detail.

Women are more likely than men to be disabled from chronic conditions. Arthritis and rheumatism, hypertension, and impairment of the back or spine decrease women’s activity level more often than they affect their male counterparts. In fact, twice as many women (24.3%) as men (11.5%) are limited in activity from arthritis and rheumatism. Women are more likely than men to have difficulty performing activities such as walking, bathing or showering, preparing meals, and doing housework (CDC, 2009d).

Functional limitations may require home health care that community health nurses supervise and deliver. Nurses plan and implement interventions based on functional assessments. The care plan facilitates optimal resumption of the individual’s independence in personal care activities.

Women are more likely than men to have surgery. Hysterectomy is the second most frequently performed major surgical procedure among women of reproductive age after C-section. Approximately 600,000 hysterectomies are performed each year (CDC, 2008g). Hysterectomy rates for women in the South are slightly higher than those in the Northeast (6.3 and 4.9 per 1000 women, respectively). Overall, rates of hysterectomy have decreased from 5.4 to 5.1 per 100 in the years 2000 to 2004 (Whiteman and Hillis, 2008).

The most common reason for hysterectomy is uterine fibroids or leiomyoma, which contributes to more than one third of all such surgeries, but considerably more for blacks (68%) than for whites (33%) (CDC, 2008g). White women more often have a diagnosis of endometriosis and uterine prolapse, which are the second and third most common reasons for hysterectomy. Hysterectomy rates are the highest in women aged 40 to 44 years (CDC, 2008g).

Optional procedures are becoming available to women. Myomectomy, or removing only the tumors with repair of the uterus, uterine artery ablation, and the use of a gonadotropin-releasing hormone to shrink the tumors can decrease the need for hysterectomy, but women may not know about these alternatives. Community health nurses function as advocates for women and can provide health education programs related to alternatives to hysterectomy, indications for hysterectomy and oophorectomy (i.e., removal of ovaries), and information regarding the type of surgical approach and the purpose of a second opinion. Second opinions and higher levels of education tend to decrease the rate of hysterectomies (Finkel and Finkel, 1990).

Birth by cesarean section is the most prevalent surgical procedure undergone by women in the United States and accounts for 32% of births. This rate has gone up more than 50% since 1996 (Hamilton, Martin, and Ventura, 2009). Several factors contribute to the high rates of C-section, including physician fear of malpractice suits, routine use of early induction of labor, and epidural anesthesia. The technology of fetal monitoring has been shown to increase the C-section rate without improving neonatal outcomes. Consumer demand has also played a part in this trend, as parents expect that the latest technological advances and advanced medical training can guarantee the “perfect baby” and report the procedure as attractive for its convenience and perceived safety. C-section is also thought of as a way to preserve the pelvic floor, despite no evidence to support this effect. C-section is a lifesaving procedure, yet should be performed judiciously for women and their babies who are at risk for life-threatening complications without the procedure. C-section involves the risks of any major surgery such as hemorrhage, infection, damage to adjacent structures, and those risks associated with anesthesia. Long-term sequelae for women include pelvic pain, along with formation of adhesions and placental abnormalities that lead to complications in subsequent pregnancies. Risks to the neonate include higher incidence of persistent pulmonary hypertension and respiratory diseases (Levine et al., 2001). Routine, high rates of C-section are not shown to improve outcomes for either mother or baby (American College of Nurse Midwives, 2005). Women should be made aware of the risks involved with interventions associated with birth and educated on how to best select their place of birth.

The most frequently occurring interruption in women’s mental health relates to depression. Well-controlled epidemiological studies consistently demonstrate that women experience depression at two to three times the rate of men (American Psychological Association, 2005). Symptoms of depression include depressed mood, apathy, anxiety, irritability, and thoughts of death and suicide (Evans et al., 1999). Unique to women are atypical symptoms including anxiety, increased appetite, weight gain, and somatic complaints along with increased rates of comorbid conditions. Women are more likely to attempt suicide but less likely to be successful (Urbanic, 2009). Women with socioeconomic barriers such as lower income and lower educational levels, racial/ethnic discrimination, unemployment, poor health, single parenthood, and high-stress jobs are at greater risk for depression than women with higher educational levels or higher economic status. Other risk factors include childhood negligence and abuse, parental death, negligence, and alcoholism (Urbanic, 2009).

Nurses practicing in community health settings should be aware of the signs and symptoms of depression and identify referral sources for professional help within the community. The nurse needs also to be aware of the impact a mother’s depression may have on her child’s development and family functioning. A woman experiencing depression may display some signs and symptoms listed in Box 17-1.

By age 32 years, half of all women report a history of at least one urinary tract infection (UTI). Peak incidence in women is ages 20 to 24 years (Foxman and Brown, 2003). In every age group, adult women have a higher incidence of UTI than men, with an annual incidence of 12.6% compared with 3% among men. The higher incidence among women is attributed to differences in anatomy, which enhance the exposure to potential uropathogens and enhance the ability of these pathogens to colonize the urinary tract.

Women often experience dysuria, the sensation of pain, burning, or discomfort on urination. Dysuria accounts for 5% to 15% of visits to family physicians; approximately 25% of American women report acute dysuria every year. The symptom is most prevalent in women 25 to 54 years of age and in those who are sexually active. Although many physicians equate dysuria with UTI, it is actually a symptom that has many potential causes, infection being only one. Treatment with antibiotics may be inappropriate, except in carefully selected patients. Risk factors for both UTI and dysuria are female gender, advancing age, sexual activity, vaginitis, renal stone, and a history of sexual abuse, which can result in psychogenic dysuria (Bremnor and Sadovsky, 2002).

At-risk women will have nonmodifiable risk factors such as increasing age, race, gender, or family history of coronary vascular disease and diabetes. Where the greatest impact can be made is with the modifiable risk factors including