“What gets measured gets improved” is a principle that has driven progress in fields from education to economics. However, this guiding truth falls painfully short in the U.S. healthcare industry, especially when it comes to women’s health.
Quality care metrics, like most aspects of healthcare, are shaped by a research landscape that has historically been centered on men. In fact, it wasn’t until 1993 that it became legally required to include women in clinical research studies. Still today, clinical studies disproportionately exclude women, fail to disaggregate data by sex, or ignore health conditions unique to women altogether.
The result? A system that measures healthcare performance against male norms, overlooking vital differences in how diseases present, progress and respond to treatment in women, as well as conditions that affect women uniquely. This leads to three profound failures: a persistent dismissal of women’s signs and symptoms, the inability to identify and close gaps in women’s health and the absence of measurement in areas critical to women’s health across their lifespan.
Compounding this, research and data collection often fail to include racially and ethnically diverse populations. Even when women are included, they are too often represented by a narrow demographic, predominantly white, middle-class participants, which leaves vast gaps in our understanding of how race, ethnicity and social determinants of health intersect with sex to influence outcomes. Without inclusive research, we also miss critical insights into how diseases manifest differently in Black, Latina, Indigenous, Asian and other underrepresented women. This lack of representation perpetuates diagnostic delays, ineffective treatments and health disparities that could be mitigated with more representative data. To drive meaningful change, we must measure what matters but also ensure those measurements reflect the rich diversity of all the people we serve.
Postpartum care: A blind spot
According to The Commonwealth Fund, the U.S. has the highest rate of maternal deaths of any high-income nation, and nearly two of three maternal deaths in the U.S. occur during the postpartum period, up to 42 days following birth. This disparity is even more severe for Black women, who are nearly three times more likely to die from pregnancy-related causes than white women, regardless of income or education. Indigenous women face similarly disproportionate risks. And women living in rural areas are about 60% more likely to die during or after childbirth compared to their urban counterparts. Although the American College of Obstetricians and Gynecologists revised its guidelines in 2018 to promote a more continuous postpartum care model, implementation has been slow and inconsistent. The American College of Obstetricians and Gynecologists recommends that postpartum care be an ongoing process with multiple touchpoints between patient and provider; however, the standard insurance coverage for postpartum care within the Obstetrical care bundle includes a single visit—typically performed at about six weeks after delivery.
The timing and standalone nature of the visit is often misaligned with the real and immediate physical and mental health needs of new mothers. Furthermore, most metrics only track whether the postpartum visit occurred, rather than what was addressed during the appointment. To that end, there is no national requirement to screen for postpartum depression, hypertension, diabetes or social needs like food insecurity, housing, transportation and intimate partner violence, despite their direct link to maternal mortality.
Endometriosis and chronic pelvic pain: A silent struggle
While endometriosis and chronic pelvic pain affect an estimated 10% of women globally, they represent some of the most underdiagnosed and undertreated conditions in women’s health.
It takes 10 years on average for people to be diagnosed with endometriosis, because its symptoms can mimic other conditions and vary widely from person to person, and there is no simple, non-invasive diagnostic test. It can also be challenging to find a doctor who has the specific knowledge and experience to identify common endometriosis symptoms.
The lack of standardized diagnostic criteria, clinical pathways, and follow-up metrics means that many patients fall through the cracks, spending years seeking answers while enduring pain. The prevalence of these conditions and their profound impact on daily life, fertility, and mental health necessitate that they be more effectively tracked, measured, and prioritized in outcomes reporting.
Perimenopause and menopause: An unmeasured life stage
Despite being a universal phase of life for women, perimenopause and menopause remain poorly tracked and inadequately addressed in clinical care. While menopause is defined retrospectively as 12 months without a period, perimenopause is the transition to menopause and can begin as early as 10 years before menopause—bringing significant physical and emotional changes.
As clinicians at a women’s health clinic, we regularly see patients who have visited multiple OB/GYNs, PCPs and other specialists without relief. Debilitating symptoms are often dismissed as “normal,” particularly if lab results demonstrate hormone values within a “normal” range, leaving patients with limited options for effective symptom management.
There is robust evidence that hormone therapy in perimenopausal and menopausal women can significantly improve quality of life and reduce serious health risks, including cardiovascular disease. Estimates suggest it can reduce hospitalizations by 50%. Yet in 2020, fewer than 5% of menopausal women in the U.S. used estrogen therapy, down from nearly 27% in 1999. This steep decline stems in part from public fear and misinformation and a lack of training among healthcare providers.
Cardiometabolic health: An overlooked priority
Cardiometabolic health, which includes conditions like hypertension, high cholesterol, insulin resistance and obesity, is a critical but often overlooked component of women’s healthcare. While heart disease remains the leading cause of death for women in the U.S., risk factors are frequently missed, under-monitored or dismissed.
This gap is especially stark during key hormonal transitions, such as pregnancy, perimenopause and menopause, when cardiometabolic risk can increase dramatically. With care models that often silo reproductive health from cardiovascular health, women are vulnerable to preventable complications like heart attack, stroke and Type 2 diabetes.
A key reason for this blind spot is that preventative screenings for chronic diseases are often gender-neutral in theory, but male-centered in practice. This leads to delayed diagnoses, mismanagement of symptoms and poor outcomes for women.
For example, risk assessment tools for cardiovascular disease do not include inputs from the chronic conditions that women regularly face. A history of pregnancy-related complications, menopause, endometriosis and PCOS are all considered significant risk factors for cardiovascular disease in women; however, these conditions are rarely factored into a woman’s risk assessment because the screening tools have been based on disease prevention in men. Additionally, there are no standard guidelines for women with these risk factors to receive earlier or more frequent cardiovascular screenings.
Improving measurement and monitoring of cardiometabolic health in women is essential to creating better preventative care strategies, outcomes and care experiences.
The path forward: Measure what matters
The U.S. health system urgently needs to update its approach to quality measurement for women’s health. This demands a systematic rethinking of what we measure, why we measure it and who is being left behind when we don’t. We need policymakers, health systems, insurers and clinicians to collaborate on comprehensive, gender-specific, life-stage-aware and equity-driven metrics.
To start, we need metrics to ensure continuity of care from menstruation to menopause. We need standard and ongoing tracking during postpartum care for conditions linked to maternal mortality; validated and trackable indicators for perimenopause and menopause care and symptom management; and gender-informed chronic disease risk assessments.
It boils down to this: incorporating existing evidence into the metrics we use to improve the quality of healthcare services will directly lead to better patient outcomes and more efficient healthcare delivery. What are we waiting for?
Barbara Levy, M.D., is chief medical officer of Visana Health. Chevon Rariy, M.D., is chief clinical innovation officer of Visana Health.