Tia Jackson-Bey, M.D., M.P.H.¹, Jerrine R. Morris, M.D., M.P.H.², Torie C. Plowden, M.D., M.P.H.³
¹ Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, College of Medicine, University of Illinois at Chicago, Chicago, IL, 60607
² Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California- San Francisco, San Francisco, California
³ Womack Army Medical Center, Department of Obstetrics and Gynecology, Fort Bragg, NC
Reproductive medicine is not immune to race-based health disparities. In fact, some of the most glaring inequities have been observed in women’s health. Reproductive endocrinology and infertility specialists work to help all patients create families. However, during that process, we cannot divorce the experience of Black women in our office from their experience in the world at large. Despite non-Hispanic Black women having higher infertility rates than non-Hispanic white women, Black women utilize infertility services at a rate half that of white women. Although cost and insurance coverage are often focal points in the conversation about pervasive disparities, we as providers must understand that there are additional factors that influence differences in healthcare outcomes. For example, Black women have lower clinical pregnancy and live birth rates compared with white women after undergoing the most potent treatment for infertility, in vitro fertilization, even after controlling for various factors. This manuscript delves into how systemic racism and unconscious biases contribute to these persistent disparities. Additionally, this piece provides tangible solutions to narrow current disparities that exist. We are calling on all providers to enact sustainable and tangible change for the betterment of our patients, particularly Black women.
While the recent murders of unarmed Black men and women exemplify the most extreme form of racial violence, pervasive and systemic racism in America affects all aspects of society, including medicine. As infertility specialists, we universally recognize infertility as a disease, affecting millions of individuals and couples worldwide. However, despite our best efforts to provide the high-quality care for all patients, the real and tangible evidence of health disparities and inequities remind us just how far we are from achieving this goal.
Reproductive medicine is not immune to race based health disparities. In fact, some of the most glaring inequities have been observed in women’s health. Indeed, J. Marion Sims, often heralded as the father of modern gynecology, performed examinations and surgical procedures on enslaved Black women without informed consent or analgesia. From Henrietta Lacks to the Fultz quadruplets and forced sterilization throughout the United States and Puerto Rico, valid accounts of unequal health, substandard treatment and lack of informed consent continue to haunt interactions between Black women in America and the medical system today. Furthermore, recent acknowledgement of the increased maternal mortality rate for Black women as more than 3 times higher than white women exposes how differences in care during the critical reproductive period can amplify inequities in the lives and experiences of Black women . As we work to help Black women create families, we cannot divorce their experience in our office from their experience in the world at large. In our goal to meet the needs of all patients, we must examine what is known and what is unknown before we can formulate adequate solutions. Attention to this aspect of infertility care is long overdue.
In addressing disparities in infertility care and treatment outcomes, we often consider access to care. Growth within our field is propelled by the demand for family building services that transcends all socioeconomic, racial, and ethnic backgrounds. However, the United States remains the only developed country that does not consider healthcare a human right; instead, healthcare is driven by market forces . Unfortunately, the most effective treatments for infertility are financially inaccessible to large segments of the infertile population, with only 24% of ART needs being met in the US . Despite Hispanic and non-Hispanic Black women having higher infertility rates than non-Hispanic white women, both groups utilize infertility services at a rate half that of white women . As a field, we are obligated to not only provide access to those seeking care, but to eliminate barriers to fertility care for those in need who are underutilizing services that could treat their disease.
Although cost and insurance coverage are often focal points in the conversation about pervasive disparities, we know there are additional factors that influence differences in healthcare. In the landmark report “Unequal Treatment: What Healthcare Providers Need to Know About Racial and Ethnic Disparities in Healthcare” the Institute of Medicine (IOM) found “while holding constant variation in insurance status, income, disease progression, comorbidities, location of care received and other patient demographic variables, there were significant disparities in the quality of healthcare received among racial and ethnic minority groups. In fact, racial differences were by and large not explained by differences in access to treatment or patients’ attitudes” . Black women discontinue fertility treatment and return for fertility treatment at a lower rate than non-Hispanic white women, regardless of IVF insurance coverage or income . This evidence clearly shows that while increasing access to care through decreased out of pocket costs and improved insurance coverage for infertility evaluation and treatment is important, unequal utilization of fertility care involves more than merely differences in insurance and socioeconomic status.
Disparities in outcomes after Assisted Reproductive Technology (ART) for ethnic minorities is a major issue which has been inadequately addressed and understood [3, 7]. For example, Black women have lower clinical pregnancy and live birth rates compared with white women after undergoing ART even after controlling for BMI and infertility diagnosis (e.g. tubal and uterine factor) [8, 9]. This suggests even after patients access treatment, ethnic minorities are less likely to achieve the ultimate goal of building their family. This added stress, in addition to chronic environmental stress of systematic racism and the stress of infertility, places these women at risk for continued morbidity from this disease. In the 5 years since this study was published, we are no closer to real and timely solutions for Black women. Why is it so difficult to close the gap?
While well aware, and critical of, research bias, many infertility providers may be less aware of unconscious biases that affect how we practice. We must reconcile how systematic racism and unconscious biases, both of which inform our interactions with individuals and whole populations of people, contribute to the current health inequities observed. Unconscious biases are social stereotypes about certain groups of people that individuals form unintentionally. Everyone holds unconscious beliefs, including the most well-intentioned physicians. In a recent survey of maternal fetal medicine specialists, there was clear inconsistency between providers’ willingness to acknowledge disparities in their practice; roughly 84% of respondents agreed that disparities impact their practice but only 29% believed personal biases affected how they care for their patients . We cannot correct a problem we fail to acknowledge exists. The sooner we confront our unconscious biases, the sooner we can have a productive discussion about how these biases detract from the patient experience and lead to inferior reproductive outcomes, particularly among Black women.
Recognizing bias and addressing racial disparities are just the tip of the iceberg to dismantle systematic racism in medicine. Diversifying the medical workforce is equally as important. Evidence demonstrates “greater diversity can improve the cultural competence of health professionals and health systems which may be associated with better health-care outcomes” . Additionally, the presence of a racially concordant provider improves trust and health care outcomes . However, despite the exponential growth of our field in recent decades, the number of underrepresented minority REIs fails to reflect our diverse patient population or diversity in other areas of medicine. Of medical school matriculants, women have not only reached parity with men but have surpassed them, although gains in diversity were not equal amongst all groups. In particular, the growth of Black medical school applicants, matriculants, and graduates lags behind other groups. The pipeline from college to medical school, then medical residency and fellowship is long, with notable attrition of minority candidates at every step. Minority candidates report less mentorship, guidance and support throughout their medical training. This culminates in fewer opportunities for research funding, stagnated promotions, and reluctance to pursue a career in academic medicine as compared to whites .
By our estimate, the fellow class of 2020 graduated only 3 black women and 0 black men out of a class of 59 fellows. To our knowledge there are no records of REI providers by race or ethnicity but there certainly exists a racial disparity amongst providers. It is also apparent that our field is not diversifying at the same rate of obstetrics and gynecology as field, indicating we are either not attracting or not retaining Black REIs . The dearth of black REIs does not serve the ASRM strategic plan to address and reduce health and racial disparities in our field as it is well documented that providers of color often take an active role in leading health disparities related research . To engender true and lasting reduction of health inequities, cultivation of minority REI physicians is paramount. Diversity in our field benefits us all. Diverse organizations are strong, creative, inclusive, and serve as a catalyst for positive organizational change.
Fundamental issues remain within medicine that inhibit the equitable provision of medical care. However, as in all things, we can use our resolve for a better world to commit to the changes we need. Transformation is often painful and circuitous, fraught with resistance, challenges, and failures along the way. We are calling on all fertility providers, partners, and the leadership of the American Society for Reproductive Medicine to be on the right side of history and enact sustainable and tangible change in reproductive endocrinology and infertility. Only by countering the dreadful legacy of slavery and overcoming the systemic racism still impacting infertility care today, will we advance our field to the next level. The time is now.
We propose the following commitments to reduce health disparities in infertility care:
- Seek ways to partner with local and national groups to increase interactions with underserved populations, reduce stigma of infertility in these communities and provide education
- Require diversity, sensitivity and unconscious bias training for all staff. Physicians must actively confront and address their own bias through honest self-reflection and a willingness to have uncomfortable and frank discussions.
- Increase the number of underrepresented minority REI physicians in practice and leadership positions a. Deliberately seek out and involve minority REIs in ASRM leadership b. Actively mentor and support medical students and residents of color c. Specifically work to diversify fellow classes d. Mentor fellow and early career professionals
- Lobby for universal coverage for infertility care
- Require reporting of race/ethnicity demographics in all SART reporting
- Develop and support quality improvement projects that can serve as the catalyst for targeted initiatives to reduce disparities
- Create a forum for patients to connect with underrepresented minority REI physicians as desired
- Increase enrollment of minority women in clinical trials
- Increase and direct funding to high quality health disparity research
- Focus on creating inclusive environments for women of all races/ethnicities
As eloquently stated by Morse et al, "physicians must engage with social movements if we expect to contribute meaningfully to improving health by addressing its social and structural determinants” . Today, we must all reconcile how deeply systemic racism affects reproductive medicine. From access to care to IVF outcomes, we are failing Black women. This, we can no longer afford to ignore.
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- Gynecology, R.a.E.D.i.O.a., Committee Opinion No. 649. Obstetrics and Gynecology 126.
- Ethics Committee of the American Society for Reproductive, M., Disparities in access to effective treatment for infertility in the United States: an Ethics Committee opinion. Fertil Steril, 2015. 104(5): p. 1104-10.
- Chandra, A., Copen, C., Stephen, E.H. , Infertility Service Use in the United States: Data From the National Survey of Family Growth, 1982–2010. National Health Statistics Reports 2014. 73: p. 1-21.
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- Jain, J., Moroz, L., Strategies to reduce disparities in maternal morbidity and mortality: Patient and provider education. Seminars in Perinatology, 2017. 41(5): p. 323-328.
- Workforce, I.o.M.U.C.o.I.a.P.-L.S.f.I.t.D.o.t.U.S.H., In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce, ed. B.D. Smedley, Stith Butler, A., Bristow, L.R. 2004, Washington (DC): National Academies Press (US).
- Evans, M., Rosenbaum, L., Malina, D., Morrissey, S., Rubin, E., Diagnosing and Treating Systemic Racism. New England Journal of Medicine, 2020.
- Nivet, M.A., Minorities in academic medicine: review of the literature. Journal of Vascular Surgery 2010. 51: p. 53S-58S.
- Rayburn, W.F., Xierali, I., Castillo-Page, L., Nivet, M., Racial and Ethnic Differences Between Obstetrician–Gynecologists and Other Adult Medical Specialists. Obstetrics & Gynecology, 2015. 127(1): p. 148-152.
- Marrast, L.M., Zallman, L., Woolhandler, S., Bor, D.H., McCormick, D., Minority Physicians’ Role in the Care of Underserved Patients: Diversifying the Physician Workforce May Be Key in Addressing Health Disparities. JAMA Intern Med, 2014. 174(2): p. 289-291.
- Morse, M., Loscalzo, J., Creating Real Change at Academic Medical Centers — How Social Movements Can Be Timely Catalysts. New England Journal of Medicine, 2020.