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Let's get real about racial bias and disparities in women's health

8 min read

A version of this article originally appeared on Well+Good.

Black women of all socioeconomic strata are impacted by racial bias in medicine and beyond — and much of it boils down to systemic injustices, stereotypes, and outward appearances. (Just recently, my mother was mistaken for a childcare provider instead of a resident in our predominantly white apartment building.) Though we’ve certainly made progress since the studies on Black patients without consent from the mid-20th century, we still have a very long way to go.

I spent 16 years (2002-2018) at Columbia University as a resident, fellow, and practicing reproductive endocrinologist. In my time there, I watched approximately 90 residents get their starts as OB-GYNs, but only a handful of us were Black. (Recent research echoes this dynamic: As of 2017, less than 6% of physicians and surgeons in the US were Black.)

In my practice, I’ve heard countless patients of minority backgrounds (particularly Black women) say that they’ve been wanting to see a doctor who shares their background and have been searching for that fit — sometimes for many years.

Without increased representation of persons of color as healthcare providers and more education about racial bias, the cycle of disparity is perpetuated. But just because this might be the current reality doesn’t mean that Black women can’t have positive medical experiences. By unpacking the issues and learning where they stem from, Black women can better advocate for themselves — and have others advocate for us, too — in the future.

What do we mean by racial bias and disparities in women’s health?

When there’s a health disparity in a specific population, that means there’s a higher overall rate of unwanted health conditions and outcomes (disease incidence, prevalence, morbidity, or mortality), and a lower rate of provided healthcare services and treatment. Though there are many populations that experience disparities in healthcare, women of racial and ethnic minority groups are the most affected. There are several ways this plays out.

Black women are less likely to seek out and receive fertility treatment

While the percentage of Black women who experience infertility is higher than white women, the American College of Obstetricians and Gynecologists (ACOG) reports that fewer Black women receive infertility treatment: An estimated 11% of Black women receive infertility treatment as compared to 16% of white women.

In one 2015 study of 1,073 women of reproductive age, researchers found that Black participants with fertility issues were 75% less likely than white participants to seek help from a doctor — and of those who did seek help, they waited about twice as long as white participants to do it.

Black women’s maternal mortality rates are three to four times higher than white women’s — and these deaths are mostly preventable.

The Centers for Disease Control and Prevention (CDC) monitored pregnancy-related deaths in the US from 2007-2016 and found that:

  • 14.2% of Black women died from cardiomyopathy (heart muscle disease that makes pumping blood more difficult) as compared to 10.4% of white women.
  • 10.9% of Black women died from thrombotic pulmonary (blood clots in the lungs’ arteries) or other embolism (artery blockages) as compared to 8.9% of white women.
  • 8.2% of Black women died from hypertensive disorders (like preeclampsia and eclampsia) as compared to 6.7% of white women.

Black women are treated less for postpartum depression

In one 2011 study of women from New Jersey with Medicaid, researchers found that only 4% of Black women initiated postpartum mental healthcare as compared to 9% of white women. Black women were also less likely to receive follow-up treatment and refill prescriptions.

Black women are more likely to be diagnosed with breast cancer at later stages

According to the American Cancer Society, the lifetime probability of Black women developing breast cancer is 11.5% as compared to 13.2% of white women — but there’s a 0.5% higher lifetime probability of Black women with breast cancer dying from the disease.

JAMA Oncology found that Black women also had higher odds of being diagnosed with breast cancer at advanced stages. They concluded that nearly half of the racial differences they observed in diagnosis were the result of limited access to health insurance (more on how that affects Black Americans specifically later). Limited access to health insurance leads to decreased access to preventative healthcare — resulting in women diagnosed with more advanced stages of disease.

More Black women are also diagnosed with cervical cancer associated with the human papillomavirus (HPV), which the CDC attributes to limited access to Pap tests and follow-up treatment.

Black women are less likely to be prescribed birth control

According to ACOG, in 2015, an estimated 29% of Black women were provided with birth control by doctors (as compared to 37% of white women) and an estimated 75% of Black women were given prenatal care in the first trimester of pregnancy (as compared to 89% of white women).

Black women are less likely to receive adequate pain management

Women of all races who experience pelvic and menstrual pain (due to conditions like endometriosis or uterine fibroids) are often told that it’s simply a natural part of being a woman. However, a 2012 meta-analysis of pain management and racial bias found that Black patients who reported pain were 22% less likely to get medication to treat it.

While it’s true that socioeconomic factors can have a major impact on reproductive health outcomes and disparities, negative experiences aren’t exclusive to women of lower income levels. Several celebrities — people who presumably have access to the best care possible — have opened up about their birth complications. Serena Williams shared that she was first ignored by her healthcare provider when she felt signs of pulmonary embolism the day after her cesarean section. In order to get the care she needed, she had to firmly advocate for herself.

Why do these disparities exist and how can we improve them?

There are many factors, both on the systemic and individual levels, that contribute to the problem. But in my experience as a healthcare provider, two that I believe have the biggest impact on access to and quality of care are systemic racism and implicit bias.

The effects of systemic racism on access to quality care

Systemic racism has an impact on many aspects of our lives — and healthcare is no exception. This problem is systemic in the truest meaning of the word: Historic injustices based on racial discrimination still influence us today because they’re actually built into many of our institutions.

The American Academy of Family Physicians explains that the healthcare facilities that exclusively served racial and ethnic minorities in the past continue to operate with limited resources — and, likely as a result of financial constraints, they tend to have higher occurrences of complications during delivery than predominantly white hospitals. What makes access to quality healthcare even more difficult is this: While segregation and discrimination in hospitals and clinics are no longer legal, discrimination based on insurance status is, which disproportionately affects Black Americans.

As of 2017, 55.5% of Black people in the US have private health insurance (as compared to 75.4% of white people), while 43.9% rely on Medicaid or public health insurance (as compared to 33.7% of white people). Meanwhile, 9.9% are completely uninsured (as compared to 5.9% of white people). However, after the Affordable Care Act was implemented, the rate of uninsured Americans, particularly Black Americans, decreased — but, in 2017, that decline plateaued.

Addressing implicit bias in healthcare

According to Howard Ross, an educator on implicit bias in health professionals, “Most unconscious bias is caused by well-intended people with blind spots.” In one cross-sectional study of 40 doctors and 269 patients in “urban community-based practices,” researchers found that race bias against Black patients was associated with doctors asserting more dominance in conversations, patients rating their experiences poorly, and doctors focusing less on the patient. The lack of Black doctors certainly doesn’t help.

Dr. Uché Blackstock, the founder and CEO of Advancing Health Equity, wrote that Black faculty members are unfairly encouraged to carry the weight of ending systemic racism and promoting racial equality at medical institutions. As she explains it: “They are often expected or told to execute ‘diversity’ efforts such as chairing diversity committees, mentoring minority trainees, and the like, and then are rarely recognized or compensated for this invaluable work.” Even when they do take on these additional duties, Dr. Blackstock says that they still get fewer mentorship, sponsorship, promotion, and advancement opportunities.

The onus belongs to the entire medical system (schools, hospitals, and the government) to fix the problems that afflict both our colleagues and patients. Thankfully, organizations like the Advancing Health Equity, Center for Reproductive Health, Black Mamas Matter, and the Association of American Medical Colleges are stepping up to effect change and put an end to healthcare disparities.

Disparities as a result of racism and implicit bias are exacerbated by the fact that doctors are pressured to see an increasing number of patients each day. To achieve that, the physician will spend less time with each individual patient. Unfortunately, correcting this would take more than simply hiring a higher number of doctors — each doctor would then earn less as a result. The increased involvement of nurse practitioners and physician assistants with subspecialty training has been helpful in addressing this issue and allows for longer, more thorough appointments.

In my experience, patients often do not understand the “system” and what limitations exist for their healthcare providers — and as a result, they may feel discouraged from seeking care or returning to their doctor when issues arise. But many of the factors that can go into a less-than-ideal healthcare experience for Black women have absolutely nothing to do with the patient. That being said, there are ways women can help foster more positive medical experiences in the future.

How to advocate for yourself in the doctor’s office

Patients of any background can prepare themselves for the best experiences possible when going to the doctor. Here’s what I recommend:

  1. Find a doctor you’re comfortable with: Sometimes it can take a few different appointments to find a doctor you feel confident in and one who is a good fit for you. It’s ultimately worth it to find someone you enjoy working with, as it may even encourage you to be more proactive about your health. (If finding a Black doctor is important to you, this site makes it easier.)
  2. Prepare in advance: Fill out your paperwork before your appointment and arrive with a basic understanding of your concerns and prepare any questions you may have. If you are going to a doctor or physician group for the first time, I’d even recommend bringing your medications with you to ensure you remember everything. Preparing will help you get the most out of your time with your doctor.
  3. Document everything: Keep a diary of your experiences or symptoms — put them in a calendar to show frequency, pain scale, and anything that provided relief. Knowing your symptoms well will help you present them clearly to your doctor.
  4. Take control of your appointments: Feel free to interrupt your doctor if you have any questions or if you don’t understand something that’s said. Remember that you’re there to have your needs met — do what it takes to make that happen.

While we can’t undo years of systemic racism or implicit bias, women can make changes that help them have positive, productive engagement with healthcare providers. In my experience, the vast majority of doctors enter the healthcare industry because they want to help people. I believe that if we continue to educate the doctors we have about implicit bias, encourage and support more Black women and men to become doctors, and always strive to advocate for what we need from our providers, we can work together to build a more positive future of healthcare.

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Dr. Nataki Douglas

Dr. Douglas is the Chair of the Modern Fertility Medical Advisory Board. She received both her M.D and Ph.D. degrees from Yale University School of Medicine.

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