Introduction

A decade of progress in behaviors, care and socioeconomic conditions did not consistently translate into better health outcomes for women and children.

• The prevalence of frequent mental distress and depression among women increased, while measures of children’s mental health worsened, marked by a decline in flourishing and rising rates of teen suicide. Overall, the prevalence of diagnosed mental health conditions among children has risen.
• Rates of maternal mortality, severe maternal morbidity and low birth weight worsened, while teen births decreased and infant well-being measures such as infant mortality and breastfeeding improved. 
• Substance use trends were also mixed. While drug deaths among women increased, rates of neonatal abstinence syndrome improved.
• Several measures of physical health among women worsened, including the prevalence of obesity and diabetes; overall, self-perceived high health status declined. Levels of physical inactivity among women remained unchanged, while physical activity decreased among children. 
• Injury and firearm death rates increased among both women and children over the past decade.
• Poverty rates among both women and children improved, as did high school and college graduation rates. Additional improvements included a reduced housing cost burden among households with children and long-term decreases in household food insecurity, though these trends have begun to reverse in recent years. 
• Several clinical care measures of access and prevention improved for women but have moved in the opposite direction for children. The rate of uninsured women and prevalence of well-woman visits improved, but the rate of uninsured children and prevalence of well-child visits worsened, despite an increase in the supply of pediatricians. Fewer children also had adequate insurance coverage or a medical home.
• Smoking patterns have shifted. Cigarette smoking among women, cigarette smoking during pregnancy and household smoke exposure among children decreased, while e-cigarette use among women rose.

• One hundred and twenty-five measures. These include 83 ranking and 42 unweighted measures (not included in a state’s overall rank). For a complete list of measures, definitions and source details, see Measures Table - Women, Measures Table - Children and Data Source Descriptions.
• Five categories of health. These comprise Health Outcomes and four categories of health determinants: Social and Economic Factors, Physical Environment, Behaviors, and Clinical Care.
• Thirty-four sources. Data are from multiple sources, including the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System, March of Dimes, the National Survey of Children’s Health and the U.S. Census Bureau’s American Community Survey.

• Presenting a holistic view of health. This report goes beyond measures of clinical care and health behaviors by considering social, economic and physical environment measures, reflecting the impact of social determinants of health.
• Providing a benchmark for states. Since 2016, the report has presented strengths, challenges and key findings for every state and the District of Columbia. Public health leaders can monitor health trends over time and compare their state’s health measures with those of other states and the nation. State Summaries are available on the America’s Health Rankings website as separate downloads.
• Highlighting differences. The report shows differences in health between states and among demographic groups at state and national levels where data are available, with groupings based on race/ethnicity, gender, age, education, income, metropolitan status, disability status, special health care needs status among children, sexual orientation and veteran status.
• Stimulating action. The report aims to drive change and improve health by drawing attention to trends and promoting data-driven discussions among individuals, community leaders, public health workers, policymakers and the media. States can incorporate population insights into their annual review of programs, and many organizations use the report as a reference when assigning goals for health improvement plans.

America’s Health Rankings is built upon the World Health Organization’s definition of health:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”¹

The model was developed under the guidance of the America’s Health Rankings Advisory Council and Committees, with insights from other rankings and health models, particularly County Health Rankings & Roadmaps

and Healthy People.

The model serves as a framework across all America’s Health Rankings reports for identifying and quantifying the drivers and outcomes that impact state and national population health.