Patient-Level Factors

Although race is a social construct that is not rooted in biological differences, it has real-world implications for the health and well-being of individuals 8 9. Historically, race and ethnicity have been used in medicine as markers of health risk (ie, individuals of one race may be more prone to certain diseases than those of another race). However, race and ethnicity alone do not confer disease risk 10. There is increased understanding that disparities in clinical outcomes by race are not biologically based. Instead, these racialized differences are a result of multiple factors, including the effects of systemic racism, clinician implicit or explicit bias (or both), and social and structural determinants of health. For example, the use of race and ethnicity variables in the vaginal birth after cesarean (or VBAC) calculator was discontinued because the inclusion of these variables may deter patients and clinicians from a trial of labor for Black or Hispanic individuals without biological cause, further perpetuating inequities in cesarean delivery rates, a contributing factor to maternal morbidity and mortality 11.

Epigenetics is the way that genetic expressions change as a result of an individual's behaviors or environment. Epigenetic changes can be caused by various environmental exposures and affect gene expression and, by extension, health outcomes 12. The role of how, and whether, a person manifests a disease is important to consider. For example, exposure to environmental toxins may lead to changes in the epigenome that negatively affect gametogenesis, ultimately resulting in reproductive health disorders or dysfunction 13. This is particularly critical because individuals who experience marginalization are more likely to also live in communities with higher levels of environmental toxicity and experience inequitable access to clean and healthy environments 14. Importantly, epigenetic changes also can be transmitted intergenerationally, affecting health outcomes for future generations 13.

Although individual health behaviors play a role in disease development, disease progression, and overall health, it is inaccurate, inadequate, and ineffective to attribute disparate outcomes solely to individual behaviors. To elucidate these connections, effectively engaging those with lived experiences of minoritization and marginalization in developing research, institutional and organizational policies, and clinical protocols and practice to advance equity is key. Understanding and promoting patient health is impossible without clinician engagement in understanding patients' experiences and fully considering the social, economic, and structural issues that may be contributing factors to overall health and well-being. Patient-level factors that affect health outcomes should be considered in the context of systematic factors.

Clinician-Level Factors

Although much of the research regarding the role of health care professionals in contributing to or mitigating health disparities has focused on the role of implicit bias in clinical care 15 16, both implicit and explicit bias have been shown to be important contributors to inequitable health outcomes 7. Despite the stated goal of many clinicians to deliver unbiased and impartial care, evidence indicates that health care professionals exhibit the same levels of implicit bias as seen in the wider population. Correlational evidence also indicates that biases can influence diagnosis and treatment decisions and levels of care 15. For example, racial and ethnic biases have been shown to affect clinicians' recommendations of contraceptive methods based on whom they believed to be at risk of unintended pregnancy. Data show that clinicians were more likely to recommend long-acting reversible contraceptive devices to Black and Latina women with low socioeconomic status than to White women who also presented for family planning care 17.

Moreover, studies exploring clinicians' implicit racial bias have demonstrated associations with diagnostic uncertainty, less patient-centeredness, poor professional communication, undertreatment of pain, and views of Black patients as less medically adherent than White patients, in addition to other biases that affect clinical outcomes and may contribute to health inequities 15. Some of these biases are tied to the reverberations of scientific racism and false beliefs about race-based biological differences. Many of these beliefs date back to the enslavement of Black people in the United States and were used to justify and uphold a hierarchy in the value of human life based on race (eg, the racist belief that a Black body can withstand more pain than a White body) 18, and they persist today, affecting clinical treatment courses. Research has shown that biological conceptions of race and related beliefs are associated with greater acceptance of racial disparities and even racial bias in pain perception, leading to undertreatment of pain in Black and Indigenous patients and a belief in the biological inevitability of racialized differences in health outcomes 19.

Although addressing these longstanding biases will take time and require multiple strategies, training in implicit bias is essential to begin to mitigate some of these inequities 20. Physicians and other health care professionals should understand the effects of implicit bias, work to increase self-awareness about their own biases, and display a “growth mindset”—the belief that personal characteristics can be developed 21 22 23. Obstetrician–gynecologists should provide care with cultural humility and in a historically informed manner in efforts to build understanding, trust, and respect for patients. Addressing biases can help support the creation of a safe and therapeutic environment that facilitates health equity and is inclusive of patients from various racial or ethnic backgrounds 23 24.

Just as patients can experience bias in care, learners who belong to groups that are underrepresented in medicine may also experience microaggressions (daily, commonplace, seemingly subtle behaviors and attitudes toward others that arise from conscious or unconscious bias) or outright discrimination 25 26 27 28 29. Systems to both report these issues and address the resulting harm should be readily available. Additionally, training to address bias can help all health care professionals understand and safely navigate these issues, ultimately leading to more inclusive learning environments 30 31. A diverse workforce is another strategy for achieving health equity. Inclusive and accountable learning environments are critical to stem the disproportionate attrition of Black, Indigenous, and other learners of color from the ranks of future obstetrician–gynecologists. Obstetrician–gynecologists should foster an anti-racist culture of learning, belonging, accountability, and continued improvement for colleagues, learners, staff, and hospital administrators.

Health Care System–Level Factors

Despite spending more per capita on health care expenditures than any other country 32, access to health care services in the United States is disparate and inequitable. This lack of access directly affects health outcomes, particularly for communities that have been historically marginalized from care. From access to insurance coverage, to representation in health care professions, to inclusion in scientific research, the structure and function of the health care system as it currently exists has a direct effect on health outcomes. As with the flawed health care system at large, obstetrician–gynecologists should acknowledge that the current system providing care for obstetric and gynecologic patients causes harm, particularly for marginalized and minoritized communities, and contributes to preventable and premature death.

Although the Affordable Care Act led to some improvements in insurance coverage across many demographics, people of color and those living on low incomes remain disproportionately overrepresented in those who are uninsured or underinsured. In addition, limitations on Medicaid expansion at the state level have halted improvements in access to health care. Research suggests that Medicaid expansion is linked to increased access to care and improvements in some health outcomes and has contributed to reductions in racial disparities in health coverage 33 34. Because most states that have not expanded Medicaid are in the South, where a larger proportion of residents are Black, Black adults are more likely to fall into this coverage gap 35. Additionally, undocumented immigrants are ineligible for coverage benefits under the Affordable Care Act, contributing to health inequities in these communities 36. Varying geographic availability of health care institutions, such as lengthy distances to care for many people living on Tribal reservations, also may contribute to racial and ethnic inequities in health care 37. Each of these factors should be contextualized in terms of the broader structural inequalities that permeate society, such as economic disparities, racism, gender oppression, and unequal educational opportunities 38.

Health care system–level factors, including racism, play a role in lack of representation in the medical field. The Association of American Medical Colleges defines underrepresented in medicine as races and ethnicities that are underrepresented in medicine compared with their representation in the general population; this includes Black, Mexican American, Indigenous, and mainland Puerto Rican individuals 39. According to the Association of American Medical Colleges, the number of Black men applying to and enrolling in medical school in 2014 was actually lower than it was in 1978, with 1,410 applications and 542 enrolled in 1978 compared with 1,337 applications and 515 enrolled in 2014 40. There are many barriers preventing changes in the number of people from underrepresented communities able to pursue medicine, including the belief that Black people may be less intelligent or less hardworking. The erroneous belief that standardized tests are the most important predictors of success in medical school also is partially responsible for underrepresentation of Black, Indigenous, Mexican American, and Puerto Rican students, whose scores are affected by differential learning and preparation opportunities and differential access to mentorship around the hidden curriculum (learning that occurs through, “informal interactions among students, faculty, and others,” or learning that occurs through, “organizational, structural, and cultural influences intrinsic to training institutions,” or both) 41, rather than differences in aptitude.

Furthermore, patients of color are more likely to report poor and discriminatory experiences when seeking health care, particularly when receiving care from racially discordant physicians. Specifically, Black patients reported poorer-quality communication and less information-giving during medical interactions with a physician of a discordant race 42. A large population-based study of more than 1 million hospital births in Florida found that newborn–physician racial concordance was associated with a substantial decrease in mortality of Black infants 43. Racial and ethnic concordance can improve health experiences and outcomes for Black, Indigenous, and other people of color. Furthermore, a diverse workforce in any setting is likely to improve patient–physician relationships, even when patients and physicians do not have racial concordance. These findings support continued efforts to increase the number of physicians from populations that are underrepresented in medicine and trainings on cultural humility and bias to improve interactions between physicians and patients of discordant races and ethnicities. With this in mind, obstetrician–gynecologists should support and assist in the recruitment, retention, and advancement of obstetrician–gynecologists and other health care professionals from racial and ethnic communities that are underrepresented in health care.

Scientific research and developments have contributed to increased life expectancy and improvements in public health outcomes and quality of life for many individuals. Unfortunately, these improvements are not universal. Many communities are either omitted from research studies or included as an afterthought. Moreover, the history of abuse and exploitation of many communities during the course of research, as well as deficit-based narratives that blame victims for their lack of success, may contribute to mistrust and distrust of the research process 44 45 46 47. However, literature has shown that willingness to participate in research is not associated with race or ethnicity 48. Addressing racial and ethnic underrepresentation in research in a trustworthy manner is a critical component of improving health inequities 46.

One suggested way to accomplish this in the field of clinical and translational research is by promoting research that actively involves communities with lived experiences and helps researchers understand the community's perspectives on their research priorities, barriers to care, assets, proposed solutions, and preferences for dissemination of findings 49. The community-engaged research approach provides an opportunity to amplify the voices of people and communities who have been marginalized and minoritized, to elevate and support community-informed interventions to address racial and ethnic health inequities, to support community participation in study design to facilitate culturally appropriate and accessible studies, and to explore and interrogate racialized narratives and beliefs that are held by the scientific community 46.

Finally, continued acknowledgement in research designs and scientific narratives that race has no biological basis could help mitigate scientific racism 50. Promoting research that not only identifies structural and cultural barriers to care, but also prioritizes understanding these barriers and creating solutions, actively engages minoritized communities with lived experiences, and tests for the effectiveness of community-informed interventions to address racial and ethnic inequities is a critical step in addressing and mitigating health inequities.

System-Level Factors

Social and structural determinants of health describe physical and social conditions—such as access to safe housing and nutritious food, experiencing racism and discrimination, police violence targeting people of color, lack of access to quality education, and mass incarceration—that influence various health outcomes 6. These system-level factors can have a profound effect on the health status of an individual and the health of communities.

Fundamentally, access to health opportunities is shaped by or driven by systematic oppressions such as structural racism or settler colonialism, which confine or constrain access to social and political determinants of health 51 52. For example, racial residential segregation (“redlining”) or historical confinement to Tribal reservations, two outcomes of structural racism and settler colonialism, play a significant role in defining access to social determinants of health such as wealth accumulation, political capital, education, health care resources, and economic investment.

In 2015, the American Public Health Association declared racism to be a public health crisis, and recently other professional medical societies and organizations, such as ACOG, the Centers for Disease Control and Prevention, the American Medical Association, and the Society for Maternal-Fetal Medicine, have identified racism as a public health threat and acknowledged the effects that racism has on health and well-being 53 54 55 56 57. Racism has been defined as a system that categorizes people by their physical attributes and provides advantages to some and disadvantages to others, ultimately sapping the strength of society as a whole 58. There is evidence that racism negatively affects the health of those who have experienced it 59 60 61. Women of color may be particularly vulnerable because they may face both racialized and gendered oppression, compounding the negative effects on their health 62. Obstetrician–gynecologists should prioritize policy changes that affect social and structural determinants of health and dismantle systemic racism at all levels and in all settings, such as voting rights; housing discrimination; living wages; affirmative action; and diversity, equity, and inclusion programs, with the understanding that these systems affect reproductive health outcomes for individuals and communities. Clinicians should be aware of these issues and actively engage in promoting policy changes to address racism and sexism.