The statistics around Black women and reproductive health disparities that we discussed in part 1 of this series are staggering.
Let’s take a deep breath and shift our thoughts to nature for just a moment—trees, to be exact. You can’t tell the history of a tree just by looking at its exterior. Instead, you’ve got to evaluate its roots, its trunk, and its leaves.
In order to understand why these bleak racial disparities exist, we have to take the same multi-level approach, starting from the roots and trunk (the health system), moving on to the branches (individual healthcare providers), and ending with the leaves (Black women patients).
What are the underlying causes of racial disparities in women’s health?
Health system-level causes
The United States is one of the few developed countries where healthcare is a privilege for some, not a fundamental right for all. Healthcare that is largely linked to employment status and socioeconomic status leaves many people without the resources they need to get and stay healthy, like high-quality insurance and medical care.
Even after the Affordable Care Act, Black women are more likely to be under- or uninsured than white women. Because of their insurance status overall, many Black women have no or limited access to preventive care, family planning, prenatal, and postpartum care.
And while public insurance is an option for some, it’s not a solution for all. In states that chose not to expand Medicaid, Black women are more likely to fall into coverage gaps than white women. Plus, the quality of care under public insurance compared to private insurance isn’t always apples-to-apples.
Almost all of these disparities can be linked back to differences in insurance coverage status and access to high-quality medical care. For example, women covered by private insurance undergo less invasive procedures for hysterectomies than women covered by public insurance do. This holds true regardless of average household income.
Racial minority women are more likely to have changes to their insurance coverage just before, during, and shortly after pregnancy. Disruptions in insurance status, such as going from public insurance to none at all, or private insurance to public, can trigger healthcare provider changes. These moving parts increase the likelihood of medical errors and oversights during care transitions, not to mention the added stress of switching providers mid-pregnancy.
In discussions that attempt to bring racial health disparities to the forefront, some participants get hung up when the conversation shifts to healthcare practitioners. They’re willing to acknowledge that the system is flawed, but reluctant to accept that to some degree, individual providers can contribute to these disparities as well.
In 2003, the Institute of Medicine (IOM) expressed that “though a myriad of sources contribute to these disparities, some evidence suggests that bias, prejudice, and stereotyping on the part of healthcare providers may contribute to differences in care.” The researchers behind this report proposed three possible explanations, including:
- Bias towards minorities
- “Greater clinical uncertainty” when interacting with minorities
- Stereotypes about minorities’ behavior
At the time this report was written in 2003, the specific ways these beliefs show up in the data was still being fleshed out, and much of the discussion around it was theoretical rather than evidence-based.
Today, attempts to better identify and understand the data around practitioner bias continues. In one study, scientists tried to figure out whether there are racial differences in the ways in which prescribers recommend long-acting reversible contraception like intrauterine devices (IUDs). While there were clear differences according to the patient’s race and socioeconomic status, the researchers had a hard time actually interpreting the data and determining why those patterns existed. The complexity of designing research that shows clear data about individual racial bias among healthcare providers has made for slow progress.
Separately, there have been calls for more diverse physician pools to better reflect societal demographics. The hope is that Black patients may have better health outcomes if they’re treated by Black physicians. As a Black public health pharmacist, I take this call a step further and encourage more representation of Black individuals throughout the entire health professions landscape.
The undercurrent of distrust in Black communities towards the US healthcare system is no secret. It’s also quite understandable. Over hundreds of years, Black people have been taken advantage of by a system that devalued and dehumanized us. We may immediately think of stories like those of Henrietta Lacks or the Tuskegee airmen, but the history of racism in the US health system runs even deeper.
The results of these offenses have been long-lasting. They may offer some insight into why Black women delay seeking medical care when confronted with issues like infertility, which ultimately delays diagnosis and treatment.
However, in the same 2003 IOM report, researchers tried to identify whether treatment refusal and negative attitudes towards treatment or medical care really had an impact on racial disparities overall. Statistically, they found, there isn’t enough of a difference from trends in other races to contribute significantly to racial disparities.
So while these patient-specific tendencies may ring true in some cases, if we really want to address racial disparities, we have to move our focus to nursing the roots and the trunk to health.
But this doesn’t mean there are no precautionary actions Black women can take to protect themselves and their reproductive health. In the last part of this series, we’ll cover ways Black women can navigate the US health system safely.