Abstract:
Starting with James Marion Sims, often referred to as the “father of gynecology” (Holland, 2017) and inventor of the speculum, a tool used to spread the vaginal opening to allow for view of the cervix, OB/GYN has a history of overt, violent racial bias. Starting in 1845, he experimented on Black enslaved women-- without anesthesia or patient consent (Holland, 2017). Historians attribute his inhumane and deplorable practices to the nearly endless mistreatment of Black women such as Henrietta Lacks, a woman who was given no financial compensation for the non-consensual removal and storage of her cervical cancer cells, which were eventually used as the foundation for revolutionary scientific research, from the making of the Polio vaccine to the effects of zero-gravity in outer space. Implicit bias and the undermining of People of Color (POC) in healthcare have existed ever since the industrialization and modernization of hospitals circa the Industrial Revolution (Skloot, 2017). Despite the fact that POC will be the majority in the U.S.A. by 2050, according to the American College of Gynecologists (Racial and Ethnic Disparities in Obstetrics and Gynecology, 2015), racial disparities in healthcare, especially OB/GYN, are imminent and extremely common.
Myriads of healthcare outcomes exist amongst different types of people-- but racial disparities such as extremely high Black mother and infant mortality (death) rates and a higher risk of preventable postpartum complications amongst POC are caveats much too large to ignore or attribute to arbitrary factors. This is just the tip of the iceberg as to OB/GYN in relation to lower quality medical care due to race and socioeconomic standing. The objective of this literature review paper is to identify the demographic differences in obstetric and gynecological conditions and explain the root cause, while opening a discussion on ways to end these disparities and why it is imperative to do so regarding long-term gynecological health.
Review:
The first and largest healthcare disparity, or significant difference in the rate of disease infection, prevalence, morbidity, and mortality in a specific group compared to the entire population (Racial and Ethnic Disparities in Obstetrics and Gynecology, 2015), is the heightened rate of infant mortality amongst Black populations as shown in the table below. While this may be attributed to tumor necrosis genes, IL-1 and IL-6 (Bryant et al., 2010), which suppress tumor growth and promote tumor regression (Omere et al., 2020), the CDC determines that foreign-born Black people (i.e. those of African descent born in Africa) have a lower risk of preterm birth or infant mortality. Upon research conducted pertaining to social circumstances, poverty and maternal stress seem to be the driving force for natal complications in the U.S.A.. Women of color (WOC) are more likely to experience stress from racism, whether that be generational trauma or recent experiences, as well as life in poorer areas with a higher concentration of pesticide use and polycyclic aromatic hydrocarbons (Bryant et al., 2010), or cancer-causing chemicals most notably found in crude oil or gasoline, which cause debilitating defects or even death. This calls to attention, not only an institutional issue, but a systemic one that has lasting ramifications on the health of WOC, who account for 36.8% of the U.S. female population (Catalyst, 2019).
Fig. 1. American College of Obstetrics-Gynecology (Racial and Ethnic Disparities in Obstetrics and Gynecology, 2015).
Obvious inequities exist in OB/GYN, and according to the Institute of Medicine, equity is one of six pinnacles of quality healthcare yet little attention has focused on healthcare quality and disparities (Howell et al., 2017). The Institute of Medicine describes quality healthcare as not only including all six pinnacles, but also “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and care consistent with current professional knowledge” (Howell et al., 2017). Despite this, Black women are three to four times more likely to die from pregnancy and twelve times more likely in New York City, attributed to a 45% decrease in maternal mortality amongst White mothers in the area and a national increase amongst the rate of maternal mortality in minorities over the past three decades (Howell et al., 2017). Furthermore, minority women pose a higher risk of suffering from pregnancy complications such as hemorrhage, diabetes, and cardiomyopathy.
It is no secret as to why: in 2015, a paper analyzing implicit bias in medical professionals and those training to be medical professionals across 15 computer-selected studies that examined anti-Black, Hispanic, and Latino bias found that 14 out of the 15 showed low to moderate levels of implicit bias against POC (Hall et al., 2015). 13 concluded that medical professionals were more likely to associate POC with negative words and concepts, such as “nasty,” “mean,” and “criminal.” 4 studies that reported moderate anti-Blackness revealed that healthcare workers perceived Black patients as less cooperative, less compliant, and less responsible with their health, attributed to higher scores on the Implicit Association Test (IAT), used to identify implicit bias based on race, gender, sex, sexuality, or ethnicity. Additionally, the IAT showed that four studies reporting anti-Hispanic/Latino bias revealed that medical professionals saw Hispanic/Latino patients as noncompliant, up to risky behavior, along with associating them with common stereotypes and caricatures (Hall, et al., 2015).
Moreover, the U.S.A. is the only developed country that does not grant universal healthcare, or access to free or affordable medical help regardless of one’s status as insured or uninsured (Racial and Ethnic Disparities in Obstetrics and Gynecology, 2015). This makes it so that those who are uninsured (usually of low socioeconomic status) have extremely high medical bills and avoid seeking medical attention/seek that of lesser quality because it is all they can afford (Raglan et al., 2013). WOC are more likely to live in poverty, and consequently, be uninsured-- causing them to receive obstetric-gynecological treatment that only occurs after pregnancy (Raglan et al., 2013), leading to poor health outcomes compared to their privately-insured counterparts.
Discussion:
One step toward stopping racial and ethnic disparities in OB/GYN is finding evidence-based research on how to acknowledge and work on reducing implicit bias for healthcare workers specifically (Hall et al., 2015). In a 2015 systematic review, research showed that although both healthcare profession students and practicing providers have similar IAT scores, providers were more likely to have implicit bias affect health outcomes due to the high stress atmosphere they work in (Hall et al., 2015). Not enough research has been focused on efficiently examining and eliminating decisions made based on anti-marginalized bias in specifically high-stress and high-stakes situations, and it is imperative that future research moves in this direction so as to ensure all women receive fair and equal treatment.
This discussion would be incomplete if systemic issues that run deeper than individual racism are not taken into account. WOC not only struggle with being seen as subliminally “criminal” or “nasty” by providers (Hall et al., 2015), but also with issues like limited access to healthcare or health insurance (Raglan et al., 2013) and stress from experiencing discrimination on a generational and individual level (Bryant et al., 2010). Obstetrics-gynecology was pioneered through racism and the exploitation of the bodies of enslaved women-- and it has a lasting legacy on women’s health outcomes as seen through heightened rates of infant mortality and risk of postpartum complications.
Issues that run deeper than racism on an individual level must be addressed and dismantled in order to achieve true equity in healthcare, especially considering the fact that it has a lasting impact on the physical and mental health of WOC. Effective ways of dismantling systemic and institutional bias in healthcare include, but are not limited to: representing darker skin tones and POC in medical literature, teaching the importance of cultural differences and the effect it has on patient-to-provider communication (Hall et al., 2015), and encouraging discussion on racism in healthcare.
References
Bryant, A. S., Worjoloh, A., Caughey, A. B., & Washington, A. E. (2010). Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants. American Journal of Obstetrics and Gynecology, 202(4), 335–343. https://doi.org/10.1016/j.ajog.2009.10.864
Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K., Eng, E., Day, S. H., & Coyne-Beasley, T. (2015). Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. American Journal of Public Health, 105(12), e60–e76. https://doi.org/10.2105/ajph.2015.302903
Holland, B. (2017, August 29). The “Father of Modern Gynecology” Performed Shocking Experiments on Enslaved Women. HISTORY; HISTORY. https://www.history.com/news/the-father-of-modern-gynecology-performed-shocking-experiments-on-slaves
Howell, E. A., & Zeitlin, J. (2017). Quality of Care and Disparities in Obstetrics. Obstetrics and Gynecology Clinics of North America, 44(1), 13–25. https://doi.org/10.1016/j.ogc.2016.10.002
Omere, C., Richardson, L., Saade, G. R., Bonney, E. A., Kechichian, T., & Menon, R. (2020). Interleukin (IL)-6: A Friend or Foe of Pregnancy and Parturition? Evidence From Functional Studies in Fetal Membrane Cells. Frontiers in Physiology, 11. https://doi.org/10.3389/fphys.2020.00891
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Raglan, G. B., Anderson, B. L., Lawrence, H., & Schulkin, J. (2013). Obstetrics and Gynecology Practices and Patient Insurance Type. Women’s Health Issues, 23(3), e161–e165. https://doi.org/10.1016/j.whi.2013.01.003
Skloot, R. (2017, April 22). Henrietta Lacks: How Her Cells Became One of the Most Important Medical Tools in History. HISTORY; HISTORY. https://www.history.com/news/rebecca-skloot-on-the-immortal-life-of-henrietta-lacks
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