The cost of racial bias in OB-GYN care
The cost of racial bias in OB-GYN care
What does racial bias look like in gynecological and uterine health? A comprehensive review which looked at multiple areas of reproductive health found racial and ethnic disparities that led to worse outcomes for women of color.
The statistics tell the story.
- Maternal mortality rates are highest for black women and American Indian/Alaska Native womenwho are 3.3 and 2.5 times more likely to die of pregnancy-related causes than white women.
- More than 14% of black babies are born preterm, with American Indian/Alaska Native infants having a preterm birth rate of 11.6% and Hispanic infants having a preterm birth rate of 9.8%. Just over 9% of White babies were born preterm (9.2%) and Asian/Pacific Islander babies had the lowest preterm rate at 8.8%. Babies born preterm are more likely to have short-term and chronic health problems than babies born after 37 weeks.
- Black women diagnosed with uterine cancer they were nearly twice as likely to die from the disease, and only 63 percent of black women survived five years after diagnosis, compared with 84 percent of white women.
In 2022 the American College of Obstetricians and Gynecologists (ACOG) issued a policy statement acknowledging how racial bias among health care professionals (HCPs) has contributed to inequalities in health outcomes.
“I think everyone has biases and that can influence a provider’s perspective,” said Jessica Shepherd, MD, OB-GYN and women’s health expert at Baylor University Medical Center and a member of the Women’s Health Advisory Council of Healthy Women. “When they walk into a room and see someone who may be of a different race,[that can influence]the options they present to that patient,” Shepherd said.
The racist origins of gynecology
To begin understanding why racial bias can manifest itself in gynecological and uterine health care, both Shepherd and Carmen Verdevice president of research and strategy at the National Birth Equity Collaborative, points to the origins of the industry. J. Marion Simsthe physician who is considered the “father of modern gynecology,” experimented on enslaved black women without the use of anesthesia or numbing agents, and an instrument he invented, the Sims speculumit is still in use today.
“We always acknowledge gynecology mothersLucy, Betsey and Anarcha, the three women we know who were used as medical tools by J. Marion Sims,” Green said. “We’re rehumanizing them and recognizing the torture experience these black women had to go through.”
That story laid the groundwork for biases and stereotypes in the medical curriculum, such as the notion that patients with darker skin have greater pain tolerance or require different procedures to cut the skin because darker skin is thicker. These false beliefs are among the reasons black women may have their pain grievances undertreated or dismissed altogether to this day.
As the United States has become more industrialized, healthcare has shifted to a more medicalized model. This put more authority in the hands of health care providers than traditional models of obstetrics which were more female-focused. The traditional model of obstetrics has allowed midwives to spend more time developing relationships with pregnant women and working to fulfill their wishes during labor and delivery.
Shepherd said she wants to have similar relationships with her patients and spend as much time as needed to help them find solutions to their concerns. When he performs comprehensive tests in response to patients experiencing pain, he is able to diagnose conditions such as fibroids, endometriosis and chronic pelvic pain and develop treatment plans. She said she often provides a second, third, or even fourth opinion for patients who have been told by other healthcare professionals that they need to have a hysterectomy or other major procedure. They often have no other options until they meet with her, he said.
“Seeing (bias) firsthand was somewhat unnerving,” Shepherd said of treating patients who were only offered hysterectomy or other invasive procedures for gynecological problems. “I do my best to educate women about their options and empathize with their journey so they can have the same decision-making autonomy as anyone else.”
Understanding the disparities in hysterectomy (removal of the uterus) The rates are also important, Shepherd said, because they illustrate one way that racial bias in ob-gyn care has hurt black women.
Black women have the highest hysterectomy rates of all racesand multiple hysterectomies are performed in the southern states, which have proportionally larger black populations. One study found that up to 90% of hysterectomies among black patients in rural hospitals occur in the South.
Some studies suggest that black women are also more likely to have the procedure at a younger age, often when they are still able to have children. High rates of hysterectomy during the reproductive years have been linked to a history of the procedure performed without consent or proper education about its risks, in fact serving as a method of forced sterilization for many black women that she wanted children or wanted more children. Black women are also more likely to suffer from uterine fibroids at a younger age, e hysterectomy is often recommended as a treatment instead of less invasive procedures.
While a hysterectomy might be the right choice for some women, healthcare professionals are advised to consider surgery as a last resort because the removal of reproductive organs can increase the risk of developing heart disease, osteoporosis, dementia, mental health problems and other health conditions.
Shepherd said such surgeries may not be necessary in many cases, and women of color could be offered less invasive procedures instead. Or, when a hysterectomy is the only option, it’s often because a reproductive problem wasn’t diagnosed or treated in earlier stages when less invasive options might have worked.
Prejudice can destroy communities
The long-term impact on every woman’s health affects entire communities. The financial, physical and mental cost of chronic pain and ill health can keep women from working, going to school, caring for a family and simply experiencing the quality of life they would like to have.
Conditions that could have been addressed through minimally invasive procedures if diagnosed earlier can become disabling or require major surgery that forces time away from work and limited movement to heal and recover.
In the worst case, there is a risk of death, from pregnancy-related causes, cancer or other conditions. Babies lose mothers and families lose loved ones.
“The systems and structures within healthcare are working together against us in so many ways,” Green said. “That’s why our supporters continue to be so engaged because we know it’s more than healthcare. The legacy of our families and communities depends so much on Black women. Anything that weakens that needs to be looked into.
Shepherd said much of the higher rate of maternal death or illness relates to missed signs, delayed action or lack of action by health care providers.
“If someone says, ‘I’m in pain’ or ‘I don’t feel well,’ that’s advancing questions that might say, ‘Hey, is this person really at high risk for this condition. We do the extra work to make sure it’s not that,” she said. “Or, ‘I know there’s a higher incidence of that happening, we do everything we can to prevent that from happening.’”
Empowering women and change workers
Both Green and Shepherd want women of color to feel empowered to advocate for their needs and for health care professionals to look into any racial biases they may have and whether it affects how they provide care. “The dynamic essentially between the person giving birth and the provider has taken on… a power dynamic with a lot of fear. And over time women haven’t been given the tools to stand up for themselves,” Green said. “It takes a culture shift to shake us out of this fear of challenging authority and shake medical professionals out of the belief that their authority usurp people’s bodily autonomy.”
The National Birth Equity Collaborative, where Green works, trains providers and birthing facilities to provide more equitable care. She also set up a research and policy arm to combat rising rates maternal mortality for black women. In an increasing number of communities, midwives and delivery centres they are providing spaces for women of color to gain more control over their birthing experience.
In the policy space, advocates say increasing access to free or affordable primary care and reproductive health care at all stages of life could go a long way in reducing racial inequities. Healthcare practitioner organizations such as ACOG have also pledged to work more collaboratively with the broader public health community and to incorporate more lessons on history and racial bias into medical school curricula.
Patients themselves are also encouraged to speak to healthcare professionals about any reproductive health concerns and seek a second opinion when needed.
Shepherd said her experiences with patients desperate for answers have shown her the importance of taking more time to make sure she addresses her patients’ concerns. She wants other healthcare professionals to do the same, and for her to be honest about how bias might affect the way they treat patients.
“I think sometimes because we’re so good at trying to fix things that are wrong, we don’t take the time to look at the person behind the problem,” Shepherd said. “It’s important to check our biases and do some internal work and ask ourselves ‘How am I contributing to this problem? What do I face individually and how can I speak up for my patients?’”
This resource was created with the support of Myovant Sciences GmbH.