Systemic Racism Persists in OB/GYN Care

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On Wednesday, Jan. 27, experts presented “Racism, Equity and Respectful Care: A Primer for MFMs,” a 2.5 hour-special topic forum that included presentations by Joia Crear-Perry, MD, of the National Birth Equity Collaborative; Elizabeth Howell, MD, MPP, chair of the Department of Obstetrics & Gynecology, Perelman School of Medicine at the University of Pennsylvania Health System; and Dorothy Roberts, JD, who is the George A. Weiss Professor of Law and Sociology and the Raymond Pace and Sadie Tanner Mossell Alexander Professor of Civil Rights at the University of Pennsylvania.

For those who may not believe that systemic racism persists in modern health care and ob/gyn in particular, experts lead their audience on a prolific historical journey that showcased policies and programs put in place and how the reverberations of those poison health care today, specifically for Black women and their babies.

Howell referred to policies that are “ingrained in our earliest institutions and continue to influence policies and practices to this day,” she said. For example, the 1935 Social Security Act, which included today’s welfare benefits, unemployment and social security. “It excluded individuals who worked farms or were domestic help, which were primarily jobs held by Black Americans and people of color in the 1930s,” she said.

“Thus, from its inception, it created a system where government aid was reserved primarily for White people. In the 1930s, the government began the practice of redlining neighborhoods based on how secure they were to invest in and redlined the neighborhoods with the highest risk,” she said. “Not surprisingly, redlined areas were occupied by Black families. Those areas rarely qualified for federal housing assistance and they become underdeveloped and it created a cycle that deterred future investment. Even though the practice was eventually banned, we still see the effects today.”

Roberts, whose works include “Killing the Black Body: Race, Reproduction, and the Meaning of Liberty,” discussed the sordid history of systemic racism and how Black women have been treated, including the effect of forced sterilization and rape at the hands of White slaveholders. Forthe 20th anniversary of its publication in 2018, Roberts wrote a preface during which she made some startling revelations.

“I was filled with exasperation because all the policies that I described back in 1997 were still present today, some, in fact, had gotten worse,” she said. She also did have excitement and an exhilaration because the movement for reproductive justice, which was just beginning when she wrote “Killing the Black Body,” had become so much more prominent.

In the present age, she implored the audience to be willing to learn about this history, and be willing to be honest and humble with themselves.

She recalled lies that were perpetrated during slavery about the “health care” of Black women, such as “This is for the good of the enslaved person; they’re going to be healthier.”

“Take account of the past that these ideas circulate today,” she said. “The worst thing you can do is say ‘I’m not racist; I don’t have to worry about that.’ Just being humble about the ideas about race, learning.”

What practicing MFMs today should do is simply to say, “I don’t understand structural racism, I don’t understand the history, I don’t understand what you mean that race was invented. Learn about it with a better consciousness of it and a humble spirit,” she said.

Howell, for her part, cited the current maternal healthcare crisis and how it is tied to quality of care. “Systemic racism has taken an extraordinary toll on the health and wellness of Black women and babies,” she said.

With data on pregnancy-related mortality for the period 2007-2016, Howell showed that Black women are nearly 3 times as likely as White women to experience a pregnancy-related death. American Indian women are more than twice as likely.

She used data from the Centers for Disease Control to show that a Black woman with a college education is more than 5 times as likely to die from a pregnancy-related cause as compared to a White woman with a college education, and a Black woman is more than 1.5 times more likely to die from a pregnancy-related cause than a White woman with less than a high school education. She cautioned that the discussion, although based around Black mothers, has implications for Brown and Indigenous birthing people. Although it focused on cisgender, that was due to the fact that much of the research is on Black cisgender women.

“These disparities are more pronounced in some of our cities and in New York City, a Black woman is 8 times more likely to die from pregnancy-related causes than a White woman. It’s important for us to recognize that these disparities go beyond class,” she said.

But Howell sought to go further. She received funding from the National Institutes of Health to do a mixed-method study to investigate contribution of hospital quality to racial and ethnic disparities in severe maternal morbidity (SMM). Via this study, she discovered a wide variation in performance across hospitals in New York City.

“In fact, a woman’s risk of having a severe morbidity event could be 6 or 7 times higher in one hospital than another,” she said.

The distribution of deliveries by race, ethnicity, and hospital ranking disclosed even more disparities. For Black women, 23% of them delivered in the low morbidity cluster of hospitals; while 65% of White women delivered in those hospitals; and 33% of Latinx. This is in contrast to high morbidity hospitals where 37% Black women delivered; 18% of White women delivered; and 29% of Latinx delivered.

Embedded in these disparities is the ongoing effect of institutional racism, she pointed out. There are several examples, including that health care segregation continued into the mid-1960s with Black families barred from certain hospitals even after the Civil Rights Act. “Hospitals serving primarily folks of color were under-resourced and we continue to see this pattern today,” she said.

In the 1930s, the government began the practice of redlining neighborhoods based on how secure they were to invest in and redlined the neighborhoods with the highest risk, she said. “Not surprisingly, redlined areas were occupied by Black families. Those areas rarely qualified for federal housing assistance and they become underdeveloped and it created a cycle that deterred future investment. Even though the practice was eventually banned, we still see the effects today,” she said.

AJPH, the publication of the American Public Health Association, last year published a study whose authors included Mary T. Bassett, MD, MPH, the previous health commissioner of New York City, which showed the historic redlining in New York City and an elevated risk of preterm birth in those neighborhoods.

Howell kept the information flowing, citing The Institute of Medicine’s landmark report in 2002, entitled “Unequal Treatment.” “It documented a wide body of research demonstrating that U.S. racial and ethnic minorities were less likely to receive preventive medical treatment, and often received lower quality of care. It also documented provider stereotyping and bias contribute to these disparities,” she said.

Equity was added to the list of aims for the U.S. health care system. “However, efforts to address equity have been given less attention than improving quality and reducing costs,” she said. “Equity was called the ‘forgotten aim’ in an Institute of Healthcare Improvement White Paper, which noted how little progress we have actually made.” (Link here for a blog post on “The Forgotten Aim” from the Institute of Healthcare Improvement).

“Further, the tumultuous events of this last year, the disproportional impact of the COVID crisis on communities of color, the murder of George Floyd by the police, the divisive election, and most recently the storming of our U.S. Capitol, these crises have put a spotlight on systemic racism and how deeply entrenched it is in our society,” Howell said. “All of these policies and practices, as well as many more, shape our current healthcare system, and underlie many of the health inequities we see today.”

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