3.2 Leading Causes of Death and Health Screenings

Maternal Complications

According to the World Health Organization (2023a), the high number of maternal deaths in some areas reflects inequalities in access to quality health services and highlights the gap between rich and underserved. Maternal morbidity and mortality are caused by complications occurring during pregnancy and/or postpartum. In 2020, rates in low-income countries were 430 deaths per 100,000 live births versus 12 per 100,000 live births in high-income countries (WHO, 2023a). Most of these pregnancy complications are preventable or treatable. Preexisting conditions can worsen during pregnancy. The WHO (2023a) reports that the major complications that account for nearly 75 percent of all maternal deaths are severe bleeding (mostly bleeding after childbirth), infections (usually after childbirth), high blood pressure during pregnancy (pre-eclampsia and eclampsia), complications from delivery, and unsafe abortion. The WHO (2023a) states that to reduce maternal deaths unintended pregnancies must be prevented. All people need access to contraception, safe abortion services, qualified health-care professionals, and quality care during pregnancy and after childbirth.

Noncommunicable Diseases

Noncommunicable diseases (NCDs) pose a substantial and growing health challenge worldwide, with persons AFAB being particularly affected. These diseases, including cardiovascular diseases, cancer, diabetes, and chronic respiratory conditions, are responsible for significant morbidity and mortality among persons across different age groups and regions.

The CDC (2022c) reports the top three causes of death for persons AFAB are heart disease, cancer, and stroke. In this population, heart disease accounts for 21 percent of deaths, with 80 percent of persons AFAB between the ages of 40 and 60 having one or more risk factors (CDC, 2022c; National Heart, Lung, and Blood Institute [NHLBI], 2023). Diseases affecting the heart and blood vessels include coronary artery disease, heart attacks, heart failure, and strokes (WHO, 2023a). Risk factors for CVD include smoking, which increases the risk of atherosclerosis, and limited physical activity, which contributes to poor cardiovascular health and obesity (NHLBI, 2023). Additionally, a diet high in saturated and trans fats, salt, and sugar can lead to high blood pressure and dyslipidemia, both risk factors for cardiovascular diseases. Risk factors for heart disease specific for persons AFAB include anemia, early menopause, history of preeclampsia/eclampsia, hormonal birth control, endometriosis, and autoimmune disease (NHLBI, 2023).

Cancer is the second leading cause of death among persons AFAB worldwide, and 20 percent of persons AFAB in the United States die from cancer (CDC, 2022c; WHO, 2023a). Various types of cancer, such as breast, cervical, ovarian, skin, colorectal, lung, and endometrial cancer, significantly impact persons AFAB (American Cancer Society, 2023a). Smoking remains a significant risk factor for multiple cancers, including lung and cervical cancer. Physical inactivity and obesity are linked to an increased likelihood of developing breast, uterine, and colorectal cancer (American Cancer Society, 2023a).

Diabetes affects millions of people globally and has a significant impact on their health and well-being (WHO, 2023a). Risk factors for diabetes include history of gestational diabetes, hypertension, hyperlipidemia, polycystic ovarian syndrome, being overweight, and having a family member with diabetes (ACOG, 2021b). Consuming excessive sugary and high-calorie foods can lead to weight gain and insulin resistance, increasing the risk of diabetes. However, engaging in regular physical activity helps maintain a healthy weight and improves insulin sensitivity.

The two most common respiratory diseases worldwide are chronic obstructive pulmonary disease (COPD) and asthma (WHO, 2023a). Smoking is a significant risk factor for COPD, and those AFAB are twice as likely to develop chronic bronchitis than persons AMAB (WHO, 2023a). Exposure to indoor and outdoor air pollution can also exacerbate respiratory conditions. Additionally, physical inactivity can negatively impact respiratory health, as regular exercise helps strengthen respiratory muscles and improves lung function.

To decrease the incidence of morbidity and mortality due to NCDs, public health policies should promote healthy self-care, such as smoking cessation, regular physical activity, and balanced and nutritious diets. Providing accessible and affordable health-care services that include preventive screenings and early detection can aid in identifying NCDs early and improving health outcomes.

Infectious Diseases

Communicable diseases can disproportionately affect persons AFAB due to the biological vulnerability of having vaginal or anal mucosal exposure to semen (National Institute of Allergy and Infectious Diseases, n.d.). Research shows that more than 9 million individuals AFAB contract an STI in the United States annually (Office on Women’s Health, 2022). Untreated STIs can cause long-term problems in those AFAB, especially chlamydia and gonorrhea, which can lead to ectopic pregnancy, chronic pelvic pain, and infertility (Office on Women’s Health, 2022).

Persons having receptive intercourse are at higher risk of contracting human immunodeficiency virus (HIV) infection; therefore, persons AFAB can contract HIV by having intercourse (anal and/or vaginal) with a partner who is HIV positive (HIV and specific populations, 2021). HIV can also be contracted through blood, such as those sharing needles. If not treated during pregnancy, HIV can be passed to the fetus via the placenta or at birth; however, pregnant persons taking antiretroviral medications greatly decrease the chance of perinatal transmission (HIV and specific populations, 2021).

COVID-19, caused by the coronavirus SARS-CoV-2, has significantly impacted populations worldwide and was the third leading causes of death in 2021 (Xu et al., 2022). While the virus does not discriminate based on gender, various social, economic, and health-related factors have led to a unique burden on persons AFAB during the pandemic. Due to closures of reproductive clinics during the pandemic and people being restricted to their homes, many e went without birth control and unintended pregnancies greatly increased (Cousins, 2020). Those pregnant during the pandemic had higher incidences of preterm birth and stillbirth, and increased rates of ventilatory support; neonatal infection was uncommon (Mullins et al., 2022). Higher incidences of hypertension were also noted in pregnant women with COVID-19 infection (Sertel & Demir, 2023).

Alzheimer’s and Other Dementias

The WHO (2023) reports that more than 55 million people have dementia worldwide. Sixty percent of these people live in low- and middle-income countries. Dementia results from diseases and injuries that affect the brain. Alzheimer’s disease, the most common type of dementia, is the cause of 60 percent to 70 percent of dementia cases (WHO, 2023b). Dementia, the seventh leading cause of death, is a major cause of disability among older people, causing dependency on family or the health-care community (Taudorf et al., 2021). Persons AFAB are affected by dementia more than persons AMAB, with 66 percent of persons with Alzheimer’s disease AFAB (Mosconi et al, 2021).

Accidents and Injuries

The leading causes of accidents and injuries in persons AFAB vary depending on age, with teens being the highest risk group; geographic location; and self-care practices (WHO, 2021b). The WHO (2021b) reports that falls are a leading cause of injuries, especially among older persons AFAB globally. In people older than 65, mortality is three to four times higher at 1 year after hip fracture with a mortality rate of 15 percent to 36 percent (Morri et al., 2019). Falls can occur due to various factors, including tripping hazards, balance issues, and environmental conditions. People may be exposed to workplace hazards that can lead to injuries such as accidents, repetitive strain, and exposure to harmful substances, with 5,190 work-related fatalities in 2021 (U.S. Bureau of Labor Statistics, 2022). Domestic and intimate partner violence can lead to severe injuries and death. One in seven persons AFAB have been injured by a partner, and intimate partner violence accounts for 15 percent of violent crimes in the United States (National Coalition Against Domestic Violence [NCADV], 2020). Intimate partner violence is responsible for 50 percent of murders of persons AFAB (NCADV, 2020).

Prevention of accidents and injuries requires education, awareness, and policy interventions. Promoting safe driving practices, providing workplace safety training, implementing measures to prevent intimate partner violence, and promoting home safety are essential steps in reducing the incidence of accidents and injuries. Factors to decrease teen violence include consistent presence of parents, teens involved in social activities, religious beliefs, and youths’ commitment to school (CDC, 2020a). Research suggests the following interventions to prevent intimate partner violence: teach healthy relationship skills, encourage protective environments, provide support to survivors, and provide treatment for at-risk families (CDC, 2017).

Mental Health Conditions

The global mental health burden in individuals AFAB is a significant public health issue. Mental health disorders are more prevalent in individuals AFAB than in individuals AMAB. Persons AFAB are twice as likely to be diagnosed with anxiety as persons AMAB, and one in five AFAB persons has a mental disorder compared to one in eight persons AMAB (Health Assured, 2023). Approximately one in three persons AFAB will experience a mental health problem in their lifetime (Lan et al., 2022). Approximately 53 percent of persons AFAB who suffer from a mental health issue have also been abused, increasing their risk for suicide and self-harm (Health Assured, 2023).

Suicide

Suicide rates among adolescents AFAB have been on the rise in recent years. Suicide is most frequent during the ages of 45 to 64 and lowest during the ages of 10 to 14 and over 70; and in 2019, 6 deaths per 100,000 persons AFAB were due to suicide (Statista, 2023). According to the WHO (2023c), 75 percent of suicides occurring nationally were committed in low- to middle-income countries, and suicide is the fourth leading cause of mortality in persons aged 15 to 29 years. Risk factors for suicide include violence, abuse, isolation, disaster, conflict, and discrimination (WHO, 2023c). Hormonal changes and social pressures of adolescence can exacerbate these issues. Adolescents may experience bullying or cyberbullying, which can significantly impact their mental well-being and increase suicide risk. In addition, issues with friends or romantic partners can be emotionally challenging and contribute to feelings of hopelessness. Academic stress and the desire to fit in with peer groups can create immense pressure, leading to emotional distress. Adolescents who are exposed to self-harm or suicide behaviors in their social circle may be at higher risk themselves.

Members of the LGBTQIA+ community are also at an elevated risk of suicidal thoughts and attempts due to persistent societal discrimination, stigma, and prejudice. Many LGBTQIA+ persons face rejection from family, friends, or religious communities, leading to feelings of isolation and lack of support. LGBTQIA+ youth may experience bullying and harassment at school or in their communities, contributing to mental health struggles.

Nurses play a crucial role in suicide risk identification and prevention within the health-care system. As frontline health-care providers, they often have frequent and direct contact with patients, making them well positioned to assess and intervene in cases of suicide risk and mental illness. Here are some key aspects of nursing roles in suicide identification and prevention:

• Screening and Assessment: Nurses are responsible for conducting initial screenings and comprehensive assessments of patients' mental health status, including assessing for suicide risk factors and warning signs. Using validated tools, they can identify at-risk patients and initiate appropriate interventions.
• Communication and Observation: Nurses must establish effective communication with patients to understand their emotional state and any suicidal ideation. They also play a critical role in observing changes in behavior, mood, and signs of distress that could indicate heightened suicide risk.
• Creating a Safe Environment: Nurses contribute to creating a safe and supportive health-care environment that promotes open discussions about mental health. By reducing stigma and fostering trust, patients may feel more comfortable disclosing suicidal thoughts.
• Risk Management and Safety Planning: When a patient is identified as being at risk for suicide, nurses collaborate with the health-care team to develop safety plans that outline strategies to keep the patient safe during crisis periods.
• Education and Support: Nurses educate patients, families, and caregivers about suicide risk factors, warning signs, and available resources. They also offer emotional support and coping strategies to patients in distress.
• Postdischarge Follow-up: Following discharge from a health-care facility, nurses may conduct postdischarge follow-up calls or visits to assess patients' ongoing well-being and ensure continuity of care.
• Documentation and Reporting: Accurate and thorough documentation of suicide risk assessments, interventions, and care plans is essential for maintaining patient safety and coordinating care.
• Self-Care and Support: Caring for patients at risk of suicide can be emotionally demanding for nurses. Practicing self-care and seeking support from colleagues and mental health professionals is crucial to maintaining their well-being.

The nurse’s role in suicide identification and prevention is integral to a comprehensive health-care approach to address this serious public health issue. By working collaboratively with other health-care professionals and organizations, nurses can help reduce suicide rates and support those in need.

Screening for Cardiovascular Risk Factors or Disease

The American College of Cardiology (ACC) and the American Heart Association (AHA) jointly released guidelines in 2019 on the primary prevention of cardiovascular disease (CVD). These guidelines recommend various aspects of CVD risk assessment, self-care practices, and medication use for those without known cardiovascular disease but at risk of developing it. Key screening recommendations are as follows (Arnett et al., 2019):

• Assessment of Cardiovascular Risk. The ACC/AHA guidelines recommend using a risk calculator, such as the ASCVD (Atherosclerotic Cardiovascular Disease) Risk Estimator Plus, to assess a person’s 10-year risk of developing a first cardiovascular event (e.g., heart attack or stroke).
• Self-care Practices. Self-care practices include promoting a heart-healthy diet, regular physical activity, smoking cessation, and weight management.
• Blood Pressure Screening. Blood pressure should be measured at least once every 2 years in adults with normal blood pressure (systolic <120 mm Hg and diastolic <80 mm Hg) and more frequently for persons with higher blood pressure.
• Cholesterol Screening. A lipid profile should be obtained in adults aged 20 years and older at least once every five years.
• Diabetes Screening. Screening for diabetes is recommended in adults with risk factors, such as overweight or obesity, sedentary lifestyle, family history of diabetes, or other risk factors for diabetes.
• Aspirin Use for Primary Prevention. Aspirin therapy is generally not recommended in persons at low risk of CVD.

The ACC/AHA guidelines on the primary prevention of cardiovascular disease are comprehensive and cover additional topics beyond screening recommendations, including treatment thresholds for cholesterol-lowering medications and blood pressure–lowering medications (Arnett et al., 2019).

Cancer is the second leading cause of mortality. Everyone is at risk of developing cancer, although the likelihood increases greatly with age; 80 percent of people diagnosed with cancer in the United States are 55 years of age or older, and 57 percent are 65 or older (American Cancer Society, 2022). The most commonly occurring cancer in persons AFAB is breast cancer; however, lung cancer is the leading cause of death by cancer in this population (American Cancer Society, 2022). A further breakdown of cancer prevalence is shown in Table 3.4. Modifiable risk factors include smoking, having excess body weight, drinking alcohol, and eating an unhealthy diet.

Mental health is also a major health concern in the United States. The CDC (2023c) estimates that 1 in 10 persons AFAB in the United States reported symptoms that suggest they experienced an episode of major depression in the past year. Suicide is a leading cause of death, especially among young persons AFAB. The National Institute of Mental Health (n.d.) recommends health-care providers use the Ask Suicide-Screening Toolkit, a four-question screening tool that can be completed in 20 seconds, for all people; the tool has adult and youth versions. Early detection for suicidal thoughts is crucial for preventing suicide. Links to this source and other screening tools include the following:

• Ask Suicide-Screening Questions (ASQ)
• Suicide Behavior Questionnaire-Revised (SBQ-R)
• Columbia Suicide Severity Rating Scale (C-SSRS)–Triage Version
• Patient Health Questionnaire–9 Adolescent Version (PHQ-9A)
• Patient Health Questionnaire 9 (PHQ-9)
• Patient Safety Screener–3 (PSS-3)

Screening for Breast Cancer—Persons of Average Risk

Breast cancer is the most diagnosed cancer in individuals AFAB in the United States and the second leading cause of cancer death (American Cancer Society, 2023b). The American College of Obstetricians and Gynecologists (ACOG, 2017) recommends that mammography screening between the ages of 40 and 49 should be a shared decision-making discussion between the person and the health-care provider to consider the potential benefits and harms of screening at this age. ACOG recommends that persons between ages 50 and 74 of average risk (see Table 3.5) have a screening mammogram every 1 to 2 years. ACOG does not recommend routine clinical breast exams for breast cancer screening in the average-risk individual. In addition, ACOG does not recommend breast self-exam (BSE) for breast cancer screening, as there is insufficient evidence to support its effectiveness in reducing mortality from breast cancer.

It is important to note that the ACOG recommendations are specifically for average-risk persons AFAB. Breast cancer is a complex disease influenced by genetic, environmental, and self-care practices. Having one or more risk factors can increase the likelihood of developing the disease. Some common risk factors for breast cancer include the following:

1. Being a person AFAB is the most significant risk factor for breast cancer. Although breast cancer can occur in persons AMAB, it is much more common in those assigned female.
2. The risk of breast cancer increases with age. Most breast cancers occur in persons over the age of 50.
3. Having a first-degree relative (parent, sibling, or child) with breast cancer increases the risk.
4. Carrying mutations in specific genes, such as BRCA1 and BRCA2, is associated with a higher risk of breast cancer.
5. Those with breast cancer in one breast are at an increased risk of developing it in the other breast.
6. Some noncancerous breast conditions, such as atypical hyperplasia, also raise the risk.
7. In addition to BRCA1 and BRCA2, other gene mutations, such as TP53, PTEN, and PALB2, can increase the risk of breast cancer.
8. Previous radiation therapy to the chest, especially during adolescence or early adulthood, increases the risk of developing breast cancer later in life.
9. Early onset of menstruation (before age 12) and late menopause (after age 55) are associated with an increased risk.
10. Having the first child after age 30 or never having children can increase the risk.
11. Persons AFAB with dense breasts on mammograms have a higher risk of breast cancer.
12. Self-care factors that increase or may increase the risk of developing breast cancer are
    1. excessive alcohol consumption;
    2. obesity, especially after menopause; and
    3. lack of physical activity.
13. White people have a slightly higher risk of breast cancer than Black, Hispanic, and Asian people. However, African American persons are more likely to be diagnosed at a younger age and have more aggressive breast cancer types.

(CDC, 2023c)

Screening for Cervical Cancer

Cervical cancer screening is an important health-care practice aimed at the early detection of cervical cancer and its precursors. Cervical cancer is a significant global health concern. The CDC reports that each year in the United States approximately 11,500 new cases of cervical cancer are diagnosed, and about 4,000 people AFAB die annually (Cervical Cancer Statistics, 2019). Cervical cancer screening has been proven to reduce the incidence of cervical cancer and related deaths significantly (Cervical Cancer Statistics, 2019).

The most common screening methods for cervical cancer include the Pap smear (Figure 3.2) and human papillomavirus (HPV) testing. The Pap smear involves collecting cells from the cervix and having a pathologist examine them under a microscope to identify abnormal cell changes. The HPV test identifies the presence of high-risk HPV strains responsible for causing most cases of cervical cancer (ACOG, 2021a).

Figure 3.2 Pap Smear Cervical cells are obtained using a broom or brush that is placed in a liquid medium for testing. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Early detection is crucial because cervical cancer found in the early stages is easier to treat (National Cancer Institute, 2023a). By detecting abnormal changes or HPV infections early, health-care providers can offer appropriate treatments, including procedures to remove precancerous lesions, reducing the risk of developing invasive cancer. Furthermore, HPV vaccination, often administered to young people before they become sexually active, complements screening efforts by preventing HPV infections and reducing the risk of developing cervical cancer later in life (ACOG, 2021a).

American College of Obstetricians and Gynecologists (2021a) and other leading gynecologic organizations endorse the U.S. Preventive Services Task Force (USPSTF) cervical cancer screening recommendations for people with average-risk. These recommendations apply to people with a cervix who do not have any signs or symptoms of cervical cancer, regardless of their sexual history or HPV vaccination status (Table 3.8).

Screening for HPV and Cervical Cancer in Transgender Persons

Transgender men with an intact cervix and uterus should continue to have cervical cancer screenings. Timing of cervical cancer screening and cervical cancer risk is the same as for cisgender persons AFAB (Dhillon et al., 2020). However, pelvic exams can cause distress to a transgender man and can trigger gender dysphoria (Dhillon et al., 2020). Due to this emotional and psychologic distress, many transgender men avoid cervical cancer screening. Nurses can play an important role in supporting the person through the exam by giving anticipatory guidance and being aware of culturally competent care (Dhillon et al., 2020).

Most anal cancers, 89 percent to 100 percent, are caused by HPV with approximately 8,300 new cases annually in the United States (Wieland & Kreuter, 2019). Risk factors for anal cancer include persons AMAB having intercourse with other persons AMAB, persons who are HIV positive, persons with a history of cervical cancer, and transplant recipients (Wieland & Kreuter, 2019). Research has shown that cervical cancer caused by HPV16 is strongly related to anal cancer caused by HPV16 (Wieland & Kreuter, 2019). Anal screening for HPV is only recommended in high-risk persons; however, it is suggested that anal screening should occur if any abnormal cervical cells are identified (Wieland & Kreuter, 2019).

Screening for Other Reproductive Cancers

Additional screenings should be offered for persons AFAB. Screenings should include ovarian, colon, endometrial, and skin cancer. In persons who smoke, lung cancer screening should also be offered.

Screening for Intimate Partner Violence

Nurses are crucial in addressing violence against persons AFAB and supporting survivors. Nurses can conduct assessments using standardized protocols to identify violence and assess safety and well-being. Nurses can collaborate with patients to develop safety plans that address their immediate safety needs.

Screening for Depression and Anxiety

Patients 18 years or older should be screened for depression at all primary care visits (Siniscalchi et al., 2020). Untreated depression can cause lost wages, emotional suffering, impaired relationships, and increased morbidity and mortality (Siniscalchi et al., 2020). Nurses can help recognize signs of depression in patients and possibly provide early intervention. Screening for anxiety should also be performed at each primary care visit. Primary care providers can determine if the anxiety is from a situation or indicative of psychiatric disorder (Centre for Addiction and Mental Health [CAMH], n.d.).

Several screening tools can be used for both depression and anxiety. The Patient Health Questionaire-9 (PHQ-9) is a nine-question tool in which the patient ranks how they have been feeling for the past 2 weeks and screens for both anxiety and depression (Siniscalchi et al., 2020). The PHQ-2 is a tool asking two questions regarding frequency of depressed mood; if positive, the PHQ-9 is then performed (Siniscalchi et al., 2020). The General Anxiety Disorder-7 is a tool specifically to screen for anxiety with seven questions determining how often the patient has felt anxious for the past 2 weeks (CAMH, n.d.). The Edinburgh Postnatal Depression Scale is the most commonly used screen during the peripartum period.