Racism in healthcare systems worsens outcomes for Black women

Maternal mortality and premature births

In the UK, maternal mortality of Black women during childbirth is four times higher than for White women¹

Although the National Health Service (NHS) has acknowledged this disparity, which has been documented for at least 20 years, there is no target end date.^1,2 Black healthcare professionals and families have expressed concern that Black women receive different treatment during pregnancy, which can lead to medical errors or even preventable deaths.³

In the USA, Black, American Indian, Alaskan Native and Latina women are more likely to experience preterm birth than White women.³ A mother’s country of birth is more strongly correlated with adverse birth outcomes than country of residence.⁴ In addition, a USA study observed a higher mortality rate of Black newborn babies cared for by White doctors than the reverse.²

The disparities are not only in maternal care — Black women are more likely to be diagnosed with diabetes and high blood pressure than White women.⁵ They are more likely to die from cardiovascular disease, hypertension, stroke, lupus and several cancers than other racial or ethnic groups.⁵

Implicit bias in healthcare

Implicit racial bias is prevalent in society and evident in healthcare.^4,6,7 Implicit bias describes cognitive processes beyond our conscious control that can influence our behaviour.⁸ This bias in healthcare can affect how clinicians make decisions and may unintentionally perpetuate inequalities.⁸ In a systematic review of US studies measuring the prevalence of negative associations against Black populations, 42–100% of healthcare professionals showed anti-Black bias.⁴

False beliefs can feed implicit bias. One false belief supports the idea that Black people’s pain is often underestimated.⁶ This could be ‘Black people have a higher pain tolerance’ or ‘Black people’s skin is thicker than white people’s skin’.⁹ The false belief that Black women do not experience the same level of pain may be a contributing factor to higher rates of maternal mortality in Black women.⁶

The accumulation of the negative effects of implicit bias can create mistrust and a lack of faith in healthcare systems and professionals.^6,7 In a literature review of 213 English articles, perceived discrimination in racial minority groups has been associated with:⁴

• A decrease in use of health and social services
• Delays in seeking treatment
• Decreased adherence to treatment

While studies exhibit correlations between implicit bias and indicators of quality of care, the complexity of implicit bias makes it difficult to measure consistently.¹⁰ More uniform measures and investigation into the relationships between multiple patient characteristics, and clinician–patient interactions, are needed to fully understand the effects.¹⁰

In countries with higher levels of implicit bias, preterm births and lower birth rates are increased⁴

Medical and social factors

Pre-existing conditions or comorbidities are a contributing factor to maternal mortality.¹ In 2018–20, 60% of women who died in the UK had a pre-existing medical condition, with diabetes and hypertension over-represented in Black and Asian women.¹ However, pre-existing conditions cannot be considered in isolation due to the interactions between genetics, lifestyle and wider socio-economic factors.¹

The contribution of socio-economic factors towards the disparities observed in Black women is well established.¹ Deeply embedded historical societal and institutional structures, such as segregation or financial practices, underlie structural racism, beyond individual implicit biases.¹¹ Structural racism influences where people live, their education, diet, lifestyle and available resources.⁵ In turn, this influences health by contributing to outcomes in elevated blood pressure, memory problems, increased risk of psychological stress conditions or other conditions.^5,12,13 Enquiries into maternal mortality in the UK have suggested there is an unmet need for ‘complex individualised care and culturally sensitive care’ in the patient experience.¹ Such nuanced care is lacking for Black women and other ethnic minorities in the UK.^1,14 How can this be addressed?

The role of medical education in closing healthcare racial disparities

There is an urgent need for cultural competency training to educate medical students and practitioners on implicit bias and critical self-reflectiveness.^9,15 Educational materials need to be updated,⁹ and healthcare systems should establish programmes^4,6 to improve patient–clinician communication and empathy.¹⁶ For example, the UK charity Five X More conducted training at Guy’s and St Thomas’ hospital entitled ‘I Am Here To Listen’ and gave badges to staff to show they had received the training.¹ One woman reported feeling reassured that her maternity healthcare professional was wearing the badge and therefore had more awareness of Black women’s experiences.¹

Recently, the UK Government and the NHS established several educational initiatives, including:¹

• ‘Continuity of care’ to provide consistency of clinical team for women from pregnancy to post-natal
• Guidance and £6.8 million in funding for local maternity systems to develop and implement equality action plans

Due to NHS staff shortages, it is not possible to implement ‘continuity of care’ safely.¹ It remains unclear how the guidance will be implemented and monitored.¹ To effectively implement such initiatives, more cooperation between governments, healthcare systems, clinicians and patients is required. Can we improve health outcomes for Black women together, or will healthcare systems continue to fail them?

References

1. Black maternal health. 2023. Available at: https://publications.parliament.uk/pa/cm5803/cmselect/cmwomeq/94/report.html.
2. Danso A, Danso Y. The complexities of race and health. Future Healthc J. 2021;8(1):22-27.
3. Averbach S, Ha D, Meadows A, Brubaker L, Gyamfi-Bannerman C. Failure to progress: structural racism in women's healthcare. eClinicalMedicine. 2023;57:101861.
4. Schnierle J, Christian-Brathwaite N, Louisias M. Implicit bias: What every pediatrician should know about the effect of bias on health and future directions. Current Problems in Pediatric and Adolescent Health Care. 2019;49(2):34-44.
5. McKoy J. Boston University. Racism, sexism, and the crisis of Black women’s health. https://www.bu.edu/articles/2023/racism-sexism-and-the-crisis-of-black-womens-health/. Accessed 4 January.
6. Sim W, Lim WH, Ng CH, Chin YH, Yaow CYL, Cheong CWZ, et al. The perspectives of health professionals and patients on racism in healthcare: A qualitative systematic review. PLOS ONE. 2021;16(8):e0255936.
7. Hamed S, Bradby H, Ahlberg BM, Thapar-Björkert S. Racism in healthcare: a scoping review. BMC Public Health. 2022;22(1).
8. Gopal DP, Chetty U, O'Donnell P, Gajria C, Blackadder-Weinstein J. Implicit bias in healthcare: clinical practice, research and decision making. Future Healthcare Journal. 2021;8(1):40-48.
9. Lim GHT, Sibanda Z, Erhabor J, Bandyopadhyay S, The N, Neurosurgery Interest G. Students’ perceptions on race in medical education and healthcare. Perspectives on Medical Education. 2021;10(2):130-134.
10. Fitzgerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Medical Ethics. 2017;18(1).
11. Braveman PA, Arkin E, Proctor D, Kauh T, Holm N. Systemic and structural racism: Definitions, examples, health damages, and approaches to dismantling. Health Affairs. 2022;41(2):171-178.
12. Jackson F, Jackson L, Jackson ZE. Developmental stage epigenetic modifications and clinical symptoms associated with the trauma and stress of enslavement and institutionalized racism. Journal of Clinical Epigenetics. 2018;04(02).
13. Berger M, Sarnyai Z. “More than skin deep”: stress neurobiology and mental health consequences of racial discrimination. Stress. 2015;18(1):1-10.
14. Knight M, Bunch K, Vousden N, Banerjee A, Cox P, Cross-Sudworth F, et al. A national cohort study and confidential enquiry to investigate ethnic disparities in maternal mortality. EClinicalMedicine. 2022;43:101237.
15. Watt K, Abbott P, Reath J. Developing cultural competence in general practitioners: an integrative review of the literature. BMC Family Practice. 2016;17(1).
16. Brown CE, Marshall AR, Snyder CR, Cueva KL, Pytel CC, Jackson SY, et al. Perspectives about racism and patient-clinician communication among black adults with serious illness. JAMA Network Open. 2023;6(7):e2321746.