Change Can’t Come Soon Enough: The Real, Life Endangering Impacts of Racial Bias in Healthcare
According to the CDC, Black, American Indian, and Alaska Native women are up to five times more likely to die of preventable, pregnancy-related issues than white women. Hypertension, blood clots, and other catastrophic medical issues are poorly identified and managed during pregnancy for these populations, with devastating results. Per the CDC’s Morbidity and Mortality Weekly Report (MMWR) from the fall of 2019, the factors working against these patients are “access to appropriate and high-quality care, missed or delayed diagnoses, and lack of knowledge among patients and providers around warning signs.” Data from the CDC suggest many pregnancy-related deaths could be avoided by addressing factors of inequity at multiple levels.
From primary care to obstetric medicine, the American healthcare system repeatedly fails Black and other BIPOC women. The unfortunate fact of the matter is that there are profound inequities in gynecological, obstetric, and breast cancer care. And while system-wide initiatives are starting to address these disparities, the changes can’t come soon enough.
The CDC’s plan to improve pregnancy-related mortality for minority women is to allot “$45 million over five years through the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) program that supports state and local Maternal Mortality Review Committees (MMRCs). They also recommend healthcare organizations “implement standardized protocols in quality improvement initiatives” and assess and address implicit bias from their individual providers and their systems at large that are negatively impacting BIPOC women patients.
Organizations such as The Black Mamas Matter Alliance are partnering with the American College of Obstetrics and Gynecology to educate providers on the ways in which Black women are being underserved in pregnancy.
Sadly, it’s not just obstetric care where Black women are being under-diagnosed, and their conditions being mis-managed. Even though the incidence of breast cancer is 4% less common in Black women than it is in white women, dying from breast cancer is 40% more likely. For those patients with breast cancer found before age 50, Black women are twice as likely to die from their breast cancer than their white counterparts, per the American Cancer Society.
Although the overall breast cancer mortality rate has continued to drop (attributed to earlier detection through breast cancer screening, increased awareness of the disease, and improvements in treatment), the disparity between Black and white patient mortality hovers around 40%. “We have been reporting this same disparity year after year for a decade. The differences in death rates are not explained by Black women having more aggressive cancers,” says Rebecca Siegel, MPH, senior scientific director of the American Cancer Society’s Cancer Surveillance. In fact, compared to all other racial/ethnic groups, Black women have the lowest 5-year relative breast cancer survival rate for every stage of diagnosis and every breast cancer subtype. “It is time for health systems to take a hard look at how they are caring differently for Black women.”
“Coordinated and concerted efforts by policymakers, healthcare systems, and providers are needed to provide optimal breast cancer care to all populations and reduce breast health disparity and accelerate progress against the disease,” reports Ahmedin Jemal, DVM, PhD, ACS senior vice president of Surveillance & Health Equity Science. “These efforts include expansion of Medicaid in the 12 non-expansion states and increased investment for new early detection methods and treatments.”
According to the Susan G. Komen foundation, “Black women face obstacles and challenges that white women do not due to a combination of factors, including barriers to early diagnosis, the aggressive nature of certain breast cancers that tend to be more common in Black women, systemic racism, discrimination, and a lack of quality care.” Their plan to improve health equity for Black women is via their Stand for H.E.R. initiative, which aims to understand and address these obstacles. Organizations advocating for expanded preventive screening, such as the Lynne Cohen Foundation, offer free services such as genetic counseling, blood tests, and mammograms to low-income women through their programs at NYU Langone, Bellevue Hospital, and USC.
Veteran breast surgeon, Dr. Denise Johnson-Miller says that one area of improvement we can make is to “Start screening mammograms for Black women and people of color earlier. Most data states the median age that Black and underrepresented minorities are diagnosed with cancer is younger than women of European Descent.” Current guidelines start annual mammograms at age forty (unless there is family history prompting earlier screening) and this may not be good enough. Studies from the National Institute of Health agree. “African-American women in the 30-39 age group have twice the age-specific distribution, have a higher incidence compared to their white counterparts, and exhibit more ominous prognostic signs… the increasing mortality and persistent racial incidence gap in young African-American women, age 30-39, argue for considering early screening mammography.”
In gynecological care, we see bleak realities for Black patients. Mortality rates related to uterine cancer rates are twice as high as in white patients and this abominable statistic hasn’t changed in decades. The American College of Obstetrics and Gynecologists is working to determine what modifiable factors contribute to this disparity. "We have an obligation to work to overhaul currently unjust systems that perpetuate unacceptable racial inequities in health outcomes," says ACOG's statement on racism in obstetrics and gynecology.
Although Black women are at the highest risk for the worst types of endometrial cancers, their symptoms are less likely to be taken seriously by providers, so cancers are missed until they are at higher, more difficult stages to treat. One of the suggested reasons that these cancers are not caught earlier is that so many Black women deal with irregular bleeding (the main symptom of uterine cancer) from uterine fibroids and other conditions, and providers ignore the guidance-concordant surveillance, wrongly assuming the bleeding is due to something “benign.”
Uterine fibroids are “benign” in that they are non-cancerous growths in the uterus, but they are not harmless. According the the N.I.H., Black women are approximately three times more likely to deal with uterine fibroids and, “African American women have fibroids diagnosed at earlier ages, are more likely to be symptomatic, and are likely to have different responses to medical treatment than white women.” Many Black women with uterine fibroids are living with chronic anemia from heavy, irregular menstrual bleeding, or chronic abdominal and pelvic pain, all of which interferes significantly with living normal, healthy lives. It’s been suggested that Black patients don’t seek treatment for abnormal bleeding as they are concerned about receiving inadequate or hostile treatment from medical providers, or because irregular bleeding is so common in their community, it doesn’t seem worth pursuing.
According to a 2022 literature review done by A.C.O.G., “Longstanding passivity about racial disparities has rested on assumptions, without evidence, of biological or genetic causes.” This is the mandate: disrupting the biases in the system that lead to providers dismissing and mistreating Black women’s conditions. We must ensure that Black women are treated proactively and with dignity. ACOG Lead for Equity Transformation Jennifer Villavicencio, MD, MPP, FACOG, says, "We recognize that as obstetrician–gynecologists, we are part of a system that perpetuates racial inequities and that our guidelines may be based on data that is flawed. ACOG has a responsibility to call this out and work with humility and accountability to correct these flaws, with the ultimate goal of decreasing health inequities."
Thanks to decades of advocacy, healthcare institutions, research organizations, and governments are just starting to acknowledge inequity in medical care. Finally, systems and individual providers are working to address the implicit biases that lead to judgements, decisions, and policies that endanger lives. Minority women need care that is safe, respectful, and reliable. Their lives need to be treated like they matter.
Sarah Zimmerman is a freelance writer in Northern California and is working on her first novel. In past lives,, she has been a Physician Assistant in Women's Health and the owner of a vegan ice cream business. Sarah writes about marriage, sex, parenting, infertility, pregnancy loss, social justice, and women's mental and physical health, always with honesty and humor. She has written for Ravishly, Cafe Mom, Pregnant Chicken, and more and can be found at sarahzwriter.com and on Medium, Twitter, Facebook, Instagram and TikTok at @sarahzwriter.