Professor, Chair, and Associate Dean of Research, College of Public Health, Division of Epidemiology, The Ohio State University, Columbus
SYNOPSIS: Black adult women in three cities in the United States describe using a range of actions to protect themselves against racism in the reproductive healthcare space.
SOURCE: Treder K, et al. Racism and the reproductive health experiences of U.S.-born Black women. Obstet Gynecol 2022;139:407-416.
Black women in the United States face higher rates of maternal and infant mortality and morbidity compared to women of other races.1 These health disparities remain even after adjusting for socioeconomic factors. This means that other factors are involved. Racism could account for some, or all, of the difference. Racism can harm health through different ways. For example, institutional racism, such as racialized residential segregation, affects social determinants of health. Also, experiencing racism can cause stress over time that can lead to inflammation and chronic disease. Furthermore, historical or present-day racism in healthcare can cause people to mistrust providers and, as a result, avoid or delay seeking needed healthcare.
Treder and colleagues conducted a qualitative study of adult, reproductive-age Black women in or close to Atlanta, Boston, and Chicago during an unspecified time interval. They sought to understand the lived experience of racism among Black women who were born in the United States. They also wanted to understand how these experiences might affect women’s decisions related to reproductive health and how they experienced reproductive healthcare. The study was limited to women who had ever had penile-vaginal sex. Treder, an OB/GYN who identifies as a cisgendered woman of color, carried out the interviews by telephone. After the call recordings were transcribed, two authors individually coded the transcriptions using their planned codes. Their codes were based on their interview questions and two theoretical models.
The first model, developed by Jones, was a framework for understanding racism that occurs on institutionalized, interpersonal, or internalized levels.2 The second model was the validated Everyday Discrimination scale, developed by Williams and colleagues.3 Treder and colleagues started coding the data while the interviews still were being conducted. This allowed them to confirm their initial understanding of the data with the subsequent participants and, thus, improve the quality of their data. The authors stopped recruiting after 21 interviews because they had reached thematic saturation, meaning the interviews were no longer uncovering new information related to their research questions. Participants were 21 to 45 years of age and all identified as cisgender women. Almost all had used contraception in the past and few (27%) had ever been pregnant.
The interviews revealed three themes. First, racism related to reproductive health occurred across the life course. For example, participants became aware in late childhood or early adolescence of the ways in which society sexualizes young Black women. They understood it as “robbing girls of their girlhood” and described how it complicated their sexual development. One woman described needing to protect herself against racial fetishizations. Others described stress and fear related to becoming sexually active or pregnant, since Black women face substantial inequities in their risk of human immunodeficiency virus (HIV) and maternal mortality.
The second theme that emerged was the racism that Black people encounter in reproductive healthcare. This included knowledge of historical racism, including forced sterilizations, unethical testing of oral contraception, the Tuskegee syphilis study, and the “immortal” HeLa line of cells, which were taken from Henrietta Lacks without her knowledge or consent. It also included personal experiences and those occurring among their family and friends. These experiences of racism included being stereotyped, such as being labeled as “promiscuous,” “irresponsible,” or “unknowledgeable,” and having their medical concerns invalidated and dismissed. For example, a participant described how her provider discounted her reports of pain during the placement of her intrauterine device. Participants also described a lack of shared decision-making and feeling pressured to conform to the provider’s agenda. For example, participants described being pressured to use or continue to use a specific method of contraception.
The third theme related the steps that participants used to protect themselves against racism in reproductive healthcare. Participants described a wide range of self-protective actions. (See Table 1.)
Table 1. Actions Reported by Participants to Protect Themselves |
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Adapted from Treder K, White KO, Woodhams E, et al. Racism and the reproductive health experiences of U.S.-born Black women. Obstet Gynecol 2022;139:407-416. |
COMMENTARY
At the time of this writing, states are actively introducing and passing legislation to ban grade schools and higher education from teaching “critical race theory” or “divisive concepts” to students. To date, at least 10 states have passed laws and 20 states are considering 38 bills involving educational “gag orders” that would censor higher education.4 Even if a given bill never goes into effect or is later overturned, it still could have far-reaching consequences. For example, uncertainty about the status of the bans or the extent of their reach could result in educators deciding to self-censor or change their course content to avoid confrontations or the threat of losing their teaching position.
The work of Treder et al is particularly timely in highlighting the need for medical providers to understand the systematic racism that has pervaded, and continues to exist in, reproductive healthcare. Banning teaching the ways racism is built into history, laws, and the practices of healthcare will make it more difficult for people to do the needed work to dismantle this. For example, in the present study, Black women referenced the unethical history of the development of oral contraception. The pill was tested on Puerto Rican women who were not informed about the product’s risks and, when women reported side effects, their reports were discounted by the researchers.5 Without awareness of these gross violations of human rights and autonomy, and the broader history of the role of racism in attempts to control the fertility of minoritized populations, medical providers will fail to understand the reasons behind patient mistrust and the ways in which patients try to protect themselves.
The Black women participating in the study by Treder et al reported using a variety of behaviors to protect themselves from experiencing racism in healthcare and its harmful effects. Through these actions, they attempted to preserve their autonomy, safety, and human dignity. For example, participants described seeking out healthcare providers who were people of color. This is an important finding, since it underscores the demand for having the healthcare workforce represent the racial and ethnic composition of the general population. This representation is critical not only for equity but also to improve people’s health. Previous research has shown that the strategy among Black patients of seeking out providers who match them on race can lead to better health outcomes, possibly because of better patient-physician communication.6 The good news is that this should be a modifiable factor in that providers could learn to communicate better with patients of different races. However, banning the discussion of “divisive concepts” in school would serve only to interfere with this learning.
Some of the adaptive strategies that participants described could have negative consequences. For example, avoiding healthcare can be understood as a rational act when viewed against the historical and contemporary treatment of Black women’s reproductive health. However, the failure to receive needed care, in some cases, could put people at risk of death or serious morbidity. Furthermore, even the act of carrying out some of the behaviors could exert a heavy toll on Black women. Constantly questioning whether an interaction was the result of racism vs. other factors, could in itself cause stress and, thus, harm health.
This carefully conducted study by Treder and colleagues uncovered Black women’s experiences with racism in reproductive healthcare. Although the findings were rich and informative about the participants’ experiences and behaviors, the study focused on a specific subset of Black women from three major cities. For example, most of the study sample had never been pregnant. Given this, the study findings might have failed to illuminate ways in which Black women have experienced and have worked to protect themselves against racism during pregnancy. Similarly, a study among rural populations might have uncovered different experiences and behaviors. Overall, the study findings underscore the critical need for healthcare providers to understand the experiences of their Black female patients to ensure they are able to provide high-quality, patient-centered care to patients of all races and ethnicities.
REFERENCES
- Hoyert DL. Maternal mortality rates in the United States, 2020. NCHS Health E-Stats. Centers for Disease Control and Prevention. Published Feb. 23, 2022. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm
- Jones CP. Levels of racism: A theoretic framework and a gardener’s tale. Am J Public Health 2000;90:1212-1215.
- Williams DR, et al. Racial differences in physical and mental health: Socio-economic status, stress and discrimination. J Health Psychol 1997;2:335-351.
- Flaherty C. Analysis: ‘Divisive concepts’ bills target higher ed in 2022. Inside Higher Ed. Published Feb. 2, 2022. https://www.insidehighered.com/quicktakes/2022/02/02/analysis-%E2%80%98divisive-concepts%E2%80%99-bills-target-higher-ed-2022
- Seaman B. The Greatest Experiment Ever Performed on Women. Exploding the Estrogen Myth. 2nd ed. Hyperion Books; 2003.
- Shen MJ, et al. The effects of race and racial concordance on patient-physician communication: A systematic review of the literature. J Racial Ethn Health Disparities 2018;5:117-140.
Black adult women in three cities in the United States describe using a range of actions to protect themselves against racism in the reproductive healthcare space.
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