As an MD/MPH student, I was drawn to obstetrics and gynecology for a multitude of reasons ranging from my enjoyment of working with birthing people to my fascination with the breadth of clinical interventions and treatments used in the field. Yet, as I considered other medical specialties throughout medical school, what continuously brought me back to obstetrics and gynecology (OB/GYN) were the stark statistics showing racial and ethnic health inequities that transcended the ways scholars had previously conceptualized and explained disparities (e.g., through socioeconomic status). African American/Black and American Indian/Alaska Native birthing people are two to three times more likely to die of a pregnancy-related cause compared to a White birthing person. When stratified by educational status, Black birthing people who have earned at least a college degree still have higher rates of pregnancy-related deaths than White women who have not graduated from high school. I carry this knowledge with me as a guide for the work I know needs to be done to dismantle and rebuild clearly non-functional systems. As I am nearing the end of graduate school and pondering my return to medical school for my fourth year and residency applications, I reflect on what keeps me galvanized in medicine.
Health inequities are not driven by biological differences but are perpetuated through racism and discrimination that are entrenched in our country. Racism can be defined as an organized social system where a “dominant racial group, based on an ideology of inferiority, categorizes and ranks people into social groups called ‘races,’ and uses its power to devalue, disempower, and differentially allocate values societal resources and opportunities to groups defined as inferior.” Structural racism extends beyond racial prejudice expressed between individuals to the systematic ways that racism is embedded in the social, political, and economic practices of a society. One way to qualify the manifestations of structural racism is by looking at three different subsets: internalized racism, interpersonal racism and institutional racism. Internalized racism describes a bias that an individual holds for their own personhood and occurs as an implicit feeling of racial inferiority or superiority. Interpersonal racism describes a prejudice between individuals that arise as intended or unintended discrimination such as hate crimes and racial slurs. Institutional racism occurs between and within organizations and encompasses acts like discriminatory practices and policies benefiting certain groups at the expense of others.
Situating our discussion of adverse maternal outcomes in the context of racism and discrimination, let us first explore how interpersonal racism impacts maternal healthcare in the United States. Interpersonal racism has its roots in a system of “othering” that prioritizes the needs of one racial group over another, reinforcing a pervasive belief of inferiority until a member of a racial group deemed inferior takes on that identity. Numerous studies and recent media reports (especially of high-profile people of color like Serena Williams) show a system where birthing people of color feel devalued, like their voices and concerns are not being heard, leading to undertreatment of serious, often fatal, medical conditions in pregnancy. Stories of discriminatory practices by healthcare providers and ancillary medical staff abound. In a nationally representative survey conducted jointly for National Public Radio (NPR), the Robert Wood Johnson Foundation, and the Harvard T.H. Chan School of Public Health, 32% of African American respondents indicated personal experience being “racially discriminated against when going to a doctor or health clinic.” Of additional concern, the same survey found that 22% of African American respondents avoided seeking medical care due to a concern for racial discrimination. NPR and ProPublica’s Lost Mothers series showcase countless articles detailing personal lived experiences of racism among women of color seeking reproductive health services. These experiences would inevitably breed mistrust and continue to perpetuate poor health outcomes.
The current practices of interpersonal racial discrimination in OB/GYN, whether intentional or otherwise, did not develop in a vacuum but were built on a long history of unequal treatment in medicine. Sexual and reproductive healthcare in the U.S. must continue to grapple with and work against its racist history. Ms. Harriett Washington, in her book “Medical Apartheid,” recalled the horrific story of J. Marion Sims, recognized as the “father of modern gynecology” and his use of enslaved Black women for medical research. The human rights violations perpetrated by Dr. Sims included performing surgery (without anesthesia) on non-consenting, enslaved Black women to establish foundational techniques and equipment still used in present-day gynecology. Having undertaken these experiments is undoubtedly egregious, yet what is most disturbing is how Dr. Sims has been celebrated for his achievements in the medical community. Dr. Sims’ contributions to the field of gynecology have long allowed him the privilege of occupying space in history texts, yielding professorships, scholarships and statues in his honor. It was not until 2018 that a prominent statue of Dr. Sims was removed from Central Park in NYC. The fact that we are only now widely confronting this history and shifting the narrative on Dr. Sims highlights the multiple decades in which the racist origins of his work were broadly accepted.
Though Dr. Sims is only one individual, his work embodies a larger phenomenon of women of color experiencing harm and trauma in medicine due to both structural factors and interpersonal biases. Another example of discriminatory practices in reproductive health is the forced, coercive sterilization of Native women, largely sanctioned by the Indian Health Service in the name of eugenics and the belief that Native women were incapable of parenting their offspring and were having too many children. A third historical example is the use of a group of socioeconomically depressed Puerto Rican women as study subjects to test the efficacy of oral contraceptive pill (OCP) regimens. Researchers believed that if a group of poor and uneducated Puerto Rican women could handle the OCP regimen, then it would not be “too complicated” for general American women. As such, the research was conducted with little regard to informed consent and dismissal of side effects and complaints (including three deaths). It should not be difficult to see how these isolated events fit a pattern of racism that worked to create unequal health systems for different communities and perpetuate that inequitable distribution of healthcare resources today.
When thinking about the origins of our healthcare system, this discussion would not be complete without acknowledging the historical prejudicial actions of the American Medical Association (AMA). The AMA is the national body promoting physician well-being with the mission “to promote the art and science of medicine and the betterment of public health,” and has a long history of actively working to bar Black as well as female physicians. “Power to Heal: Medicare and the Civil Rights Revolution” provides insight into the nuances of the battle to integrate the AMA as well as the AMA’s push against integrating hospitals. As an organization, the AMA has wielded its platform to lobby government officials to design policies that have historically benefitted White males (as well as, to a lesser extent, White females). For example, throughout the beginning of the 20th century, the AMA played a role in deciding where hospitals should be built and how hospitals should operate in terms of limiting the number of beds for Black patients or creating situations where hospitals for Black patients were under-funded or under-resourced. In doing so, the AMA has sought to create institutions of medicine based on racist ideals which have persisted into the present day. Over the past decade, the AMA has attempted to confront its racist history through submitting an official apology for past discriminatory practices, increasing diverse representation in leadership, holding task forces and committees and conducting an internal review. Though this represents a step towards justice, more work needs to be done.
From my perspective as a medical student, I am proud to say that from our first year of medical school, our teaching around health disparities has been grounded in critical race theory. Yet as one of the few medical students of color at my institution, I am still painfully aware of the structures in place that were not built to serve me and my home community and to educate students on the intricacies of racism in medicine. Because of the entrenched history of racism and discrimination in medicine, our discussions of race in medical school have been awkward and met with resistance. For example, I remember overhearing a conversation among fellow students where one student was complaining about a test question, noting that it was purposeless and there were so many more important concepts to learn. The question was: “True or False? Racism is the root cause of racial disparities in maternal health outcomes.” I have also found that the majority of my faculty and attending physicians do not understand how structural racism impacts their patients and/or believe that these issues can be solved with “implicit bias training.” In the first few months of medical school, our class underwent a session that was supposed to teach us skills to contend with bias and racism in a clinical setting. I vividly recall a professor (a White woman) telling me that, as a medical student of color, I should learn how to be polite and understanding of patients should they say anything racist to me. In the face of my personal experiences in medicine and its history with racism, it is difficult for me to imagine how we continue to bend the arc of history towards equity, but I am hopeful that we are making incremental changes towards that.
As I reflect on exploring structural racism in medicine, I think about the type of OB/GYN physician I hope to be for my future patients. As an exercise, I looked into the American College of Obstetricians and Gynecologists (ACOG)’s official statements on addressing racism. Endorsed by over 20 professional organizations engaged in women’s health, I was pleased to see that the statement explicitly names systemic racism as a root cause of disparities and persistent inequities in women’s health. Additionally, ACOG recently published a new framework for addressing equity issues in OB/GYN. The framework is called “Reproductive and Sexual Health Equity“ and applies the principles of Reproductive Justice to ground our approach to women’s health in a more life-course perspective. This new framework calls for an awareness of structural factors that impact a person’s ability to access resources to sustain health. I am hopeful for this new movement in the field of women’s health and look forward to pushing this work ahead as a future OB/GYN.
Image credit: maternity in low key 1 by j3ffm4n is licensed under CC BY 2.0.