Pre-Collegiate Global Health Review
A Review of Racial Disparities in Obstetrics-Gynecology (OB/GYN) in the United States
Jasmine Ispasoiu, Saratoga High School, Saratoga, California, USA
Starting with James Marion Sims, often referred to as the “father of gynecology” 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. Beginning in 1845, Sims experimented on enslaved Black women without anesthesia or patient consent (Holland, 2017). Historians attribute his inhumane practices to the endless other incidences of mistreatment of Black women. One such example was Henrietta Lacks, a patient at Johns Hopkins Hospital in 1951, who was given no financial compensation for the non-consensual removal and storage of her cervical cancer cells. Implicit bias and the undermining of People of Color (POC) in healthcare have existed since the industrialization and modernization of hospitals circa the Industrial Revolution (Skloot, 2017).
According to the National Academy of Medicine, equity is one of the six pinnacles of quality healthcare. However, little attention has been focused on healthcare quality and disparities. The National Academy of Medicine describes quality healthcare as not only including all six pinnacles, but also as “the degree to which health services… increase the likelihood of desired health outcomes” (Howell et al., 2017). Despite the fact that POC will make up the majority of the U.S. population by 2050, racial disparities in healthcare, especially OB/GYN, are imminent (Racial and Ethnic Disparities in Obstetrics and Gynecology, 2015). The objective of this literature review paper is to explain the root cause for demographic differences in obstetric and gynecological conditions among different Women of Color (WOC), while opening a discussion on ways to end these disparities.
The first and largest healthcare disparity is the heightened rate of infant mortality amongst WOC as shown in Figure 1. 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. WOC are more likely to experience stress from racism, whether that be generational trauma or recent experiences, as well as living conditions in poorer areas where there is a higher concentration of pesticide use and cancer-causing chemicals in the environment, causing debilitating birth defects (Bryant et al., 2010). For example, Black women experience 11.2 fetal deaths per 1,000 live births, while Hispanic and non-Hispanic White women experience around 5 fetal deaths per 1,000 live births (Pruitt et al., 2020). This calls to attention a systemic issue that has lasting ramifications on the health of WOC, who account for 36.8% of the U.S. female population (Catalyst, 2019).
Figure 1. Comparison between fetal mortality rates and race per 1,000 live births.
Additionally, Black women are three to four times more likely to die from pregnancy complications. The rate of maternal mortality among Black women increased nationally from 18.6 deaths per 100,000 live births in 1990 to 55.3 in 2020 (Maternal Mortality Rates in the United States, 2022). Furthermore, minority women face a higher risk of suffering from pregnancy complications including hemorrhage, diabetes, and cardiomyopathy.
In 2015, a paper analyzed 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 via the Harvard Implicit Association Test (IAT). 14 out of the 15 studies 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. Additionally, the IAT showed that four studies reporting anti-Hispanic/Latino bias revealed that medical professionals saw Hispanic/Latino patients as noncompliant and up to risky behavior, associating them with common stereotypes and racist caricatures (Greenwald, et al.). These findings suggest racial bias contributes to poorer health outcomes among POC due to providers forming negative opinions of patients of color before they are even examined.
The U.S.A. is the only developed country that does not grant universal healthcare or access to affordable medical help regardless of one’s status as insured or uninsured (Racial and Ethnic Disparities in Obstetrics and Gynecology, 2015). Consequently, those who are uninsured (usually of low socioeconomic status) have extremely high medical bills and avoid seeking quality medical attention (Raglan et al., 2013). Compared to White women, WOC, specifically Black and Brown women, are more likely to live in poverty due to systemic disadvantages
including but not limited to: the salient legacy of enslavement and Indigenous colonization and erasure in the U.S., causing Black and Brown people to experience poorer living conditions, education, and nutrition. As a result, Black and Brown POC remain more likely to be uninsured (Health Coverage by Race and Ethnicity, 2010-2019, 2021). This results in obstetric-gynecological treatment that only occurs after pregnancy, leading to poor health outcomes from the lack of natal care (Raglan et al., 2013).
One step toward eliminating racial and ethnic disparities in OB/GYN is finding evidence-based research on how to acknowledge and work towards reducing implicit bias among healthcare workers. 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 affecting their patients’ health outcomes (Hall et al., 2015). It is imperative that future research focuses on addressing this issue to ensure all women receive fair and equal treatment.
Systemic issues that run deeper than individual racism must be taken into account when discussing racism in obstetrics-gynecology. WOC not only struggle with being seen as subliminally “criminal” or “nasty” by providers, but also face issues including limited access to healthcare 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, which has a lasting legacy on women’s health outcomes.
Systemic issues must be addressed and dismantled in order to achieve more equitable treatment of OB/GYN patients, especially considering that systemic and institutional discrimination have 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, especially in academia.
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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.
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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.
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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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Pruitt, S. M., Hoyert, D. L., Anderson, K. N., Martin, J., Waddell, L., Duke, C., Honein, M. A., & Reefhuis, J. (2020). Racial and Ethnic Disparities in Fetal Deaths — United States, 2015–2017. MMWR. Morbidity and Mortality Weekly Report, 69(37), 1277–1282. https://doi.org/10.15585/mmwr.mm6937a1.
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