As primary care clinicians, it is important to recognize the causes of health disparities in our patients who are women of color in order to advocate and work toward true equity in health outcomes. This article strives to introduce this concept by presenting areas of inequity such as maternal mortality, management of pain, cardiovascular health, and breast cancer outcomes. Lastly, we will introduce a framework and actionable steps that can be taken to counteract the biases known to influence patient care.
Key points
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Racial Bias and Racism are linked to health disparities in communities of color.
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For Women, these inequalities are especially evident: that is, maternal mortality, management of pain, cardiovascular health, and breast cancer outcomes.
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As Primary care clinicians, it is critical that we recognize the causes of these health disparities and use an intersectionality framework to advocate and work toward true equity in health outcomes for our patients of color.
Introduction
There is a stark difference in mortality and morbidity experienced by women of color (WOC) in America. We suggest that you reflect on your own identity and how it, as well as your lived experiences, including your medical education, may affect the way that this information impacts you as you read this article. Table 1 below defines key terms essential for your review of subsequent sections of the article.
| Health Inequities | Differences in health outcomes that are systematic, avoidable, and unjust arise from systematic discrimination or exclusion due to societal barriers, are often patterned , and are not caused by patients. |
| Implicit (or unconscious) Bias | The automatic activation of stereotypes derived from common cultural experiences, which may override deliberate thought and influence one’s judgment in unintentional and unrecognized ways and may affect communication behaviors and treatment decisions . |
| Social Determinants of Health | The conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks . |
Healthcare Disparities
The United States is increasingly diverse. Approximately 42% of the population belongs to a racial or ethnic minority according to the 2020 US Census. Despite many health indicators improving, certain minority groups bear a disproportionate burden of avoidable disease, death and disability compared to nonminority populations. For instance, in 2017, the life expectancy at birth of a non-Hispanic (NH) Black woman was only 77.9 years, compared to 81.0 years for an NH White woman ( Fig. 1 ).
The Historical Basis for Health Inequities in the United States
In order to address health inequities, clinicians should review the timeline of policies and events that occurred, and consider why we, as a health care system, have not earned the trust of communities of color. There is a complex history that contributes to mistrust among many populations when engaging with health care systems.
Medical harm
Examples of ethically unjustified studies and research misconduct are covered later in this text (eg, The US Public Health Service untreated syphilis study at Tuskegee, and use of the cancer cells of Henrietta Lacks without the patient’s or family’s knowledge or consent), but highlight the legacy of broken trust between Americans, particularly Black Americans, and the medical establishment.
Lack of representation in medical research
The lack of adequate representation of women, especially WOC, in clinical trials limits medical understanding and contributes to health inequities and social injustice.
In 1977, the Federal Drug Administration issued guidelines excluding reproductive-age women from early-phase clinical research unless they faced life-threatening conditions in response to birth defects caused by prior research on thalidomide. This further reduced poor representation and lead to diagnoses and treatments based on male-only trials. For example, The New England Journal of Medicine’s 1989 study establishing that aspirin reduced the risk of myocardial infarction (MI) was based on 22,071 participants but notably, no women. Additionally, the landmark Framingham Heart Study, initially lacked racial diversity, which limited the applicability of its findings to non-White populations.
The 1985 US Public Health Service Task Force concluded that the historical lack of research focus on women’s health concerns has compromised the quality of health information available to women, as well as the health care they receive . In response, federal agencies established policies for including women and minorities in clinical research. In 1993, the National Institutes of Health (NIH) mandated their inclusion and required NIH-funded research to analyze differences in effects. While these mandates have somewhat improved participant demographics, continued efforts are needed.
Reproductive coercion
Reproductive coercion, state or societal sanctioned as well as within a relationship or family, has been linked to poor mental health, increased sexually transmitted disease among other issues. This history of reproductive coercion begins with slavery. The decision of when to conceive, when not to, with whom, and whether to parent that child was within the purview of the slave owner. Since then, it has taken other forms. Dr Marion Sims performed procedures without anesthesia on WOC in slavery ( Fig. 2 ). The Mississippi appendectomy , removal of uterus or tubal ligation without consent, was done on thousands of women from the 1920s to 1970s. The first birth control was tested without informed consent on women in Puerto Rico. The Family Planning Act led to sterilization of 25% of reproductive age indigenous women in the 1970s.
Disparities in Women’s Health
Maternal mortality
Maternal mortality (MM) in the United States continues to be significantly higher than any other similarly high resource country. Recent data cites that 80% of these deaths are preventable. The Centers for Disease Control and Prevention data shows that the rate of death is disproportionately higher in Black women (BW). This disparity is persistent even in BW with higher education, access to prenatal care, and younger age and has persisted despite improvements seen in rates of MM of White women. This inequity has been maintained overtime ( Fig. 3 ).
Bias shows up in care of peripartum diverse women. From 1988 to 1999, rates of preeclampsia, preterm labor, and other maternal morbidities were not significantly different between racial groups. However, BW were 2 to 3 times more likely to die secondary to these complications than their white counterparts. With no biological or pathologic reason, one must consider the gap due, at least in part, to bias of the clinician and systemic racism.
Mitigating the inequity must be done at both the microlevel and macrolevel. Clinicians need to recognize internal biases when managing patients who are WOC. On a macro level, policies should aim to decrease barriers to care, healthy food, and safe communities while providing resources for healthy lifestyles and paid leave. California’s strategic plan is an example of state policy change created to decrease disparities by providing BW within their state with increased support during the peripartum period.
Management of pain
Clinicians disproportionately underestimate, undertreat, or dismiss pain suffered by women, people of color, and those with lower socioeconomic status, even when patients undergo similar medical procedures or present with similar findings. ,
One study demonstrated that women with acute abdominal pain in emergency departments were less likely to receive analgesia, including opioids, and waited longer for pain relief compared to men, even after controlling for factors like age and pain score. Research indicates that women’s pain is often not taken as seriously as men’s. This may explain why, despite reports of significant discomfort and studied pain relief methods, procedures like intrauterine device insertions are frequently done without anesthesia other than non-steroidal anti-inflammatory drugs. ,
Further disparities in pain treatment persist, with Black and Latinx/Hispanic (L/H) patients often undertreated compared to White patients. , A study found that many medical learners believed in biological differences, such as Black people’s skin is thicker than White people’s . Those holding such beliefs rated Black patients’ pain lower and made less accurate treatment recommendations. In a study of postpartum pain, despite higher pain scores, WOC received fewer inpatient opioid doses and were less likely to get an opioid prescription at discharge. The differences in pain management were not due to less perceived pain.
Addressing pain is subjective and thus challenging. Using objective findings and guidelines can help reduce subjective bias and prevent discriminatory care.
Cardiovascular disease
There is a well-established gap between the care of women versus men in treatment and prevention of cardiovascular disease and it is widened when cardiovascular outcomes are compared between NH white women and WOC. A BW is over 30% more likely to die of cardiovascular disease than an NH White woman. This risk is more evident when you exclude women over 65 and are consistent across different aspects of cardiovascular morbidity and mortality ( Fig. 4 ). , Management of cardiovascular disease in women is reviewed in a later chapter.
