While Black women are almost twice as likely to experience infertility, only 8% actually seek fertility treatment (compared to 15% of white women). Statistics like these, compounded by the fact that Black women are three times as likely to die from pregnancy-related causes, highlight inequalities in reproductive healthcare that must be addressed.
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As a Nurse Practitioner working in the medical field who also happens to be a woman of color, I have a unique perspective on the state of fertility care. The racial disparities between Black women and white women when it comes to reproductive and maternal health outcomes are shocking.
Black women are twice as likely to struggle with infertility than their white counterparts, due in part to a higher prevalence of uterine fibroids, ovulatory dysfunction, and tubal disease.
Many studies show that Black women also have higher rates of pregnancy loss, including miscarriages and stillbirths, compared to white women. This is likely due to the fact that Black women have higher rates of risk factors that are associated with pregnancy loss. These include obesity, diabetes, and low socioeconomic status.
For Black women, the isolation of infertility is compounded by various factors (for example, cultural stigma, socioeconomic barriers and racial bias) that prevent them from getting the care they need. Those who do end up seeking care often find themselves feeling deeply uncomfortable in the medical space, which is still predominantly white.
Throughout my career, I have witnessed the positive impact of diversity in healthcare providers and the power of culturally-competent care and education. Let's talk about why these things are so vital, how they help improve access to care, and even improve treatment outcomes.
Why is diversity in healthcare providers so important?
It is important for people of color to have access to BIPOC (Black, Indigenous, and People of Color) healthcare providers because it provides a sense of comfort and familiarity. BIPOC healthcare providers possess culturally-specific knowledge, skills, and experience that helps with the communication and health management process involving people of color.
Diversity in providers helps reduce barriers to the patient-physician relationship for racial/ethnic and linguistic minority patients.
Here's why: In many situations, seeing someone that looks like you and understands your cultural background brings comfort and reassurance, increasing comfort levels and improving communication between patients and care professionals.
Many studies have shown that there are better health outcomes when patients of color are seen by BIPOC providers. A result of this is increased trust and communication developed between the patient and provider. The patient may also feel that someone who has a similar cultural experience to them is easier to share things with.
BIPOC providers also have insight into the specific and nuanced experiences of other people of color. They also bring an unspoken understanding of what the patient may be going through. Additionally, Black women who have a provider with similar cultural history may feel more comfortable speaking up and advocating for themselves.
Note: Many people of color have a (warranted) sense of mistrust when it comes to our healthcare system, due to historical practices based on racist ideals. As healthcare providers, we need to remain dedicated to bridging the gap to improve outcomes for patients of color.
Long-held beliefs, stereotypes, cultural stigma and other issues continue to uphold these racial disparities around fertility and family-building. Here are some examples of the various factors that contribute to widening the gap in care for Black women:
Both of these issues heavily contribute to racial disparities in fertility and maternal healthcare in different ways. Structural racism goes beyond the individual. It refers to inherently racist laws, rules, economic practices, and cultural and societal norms that are embedded in the system itself.
Implicit (or unconscious) bias occurs automatically and unintentionally, nevertheless affecting our judgments, decisions, and behaviors. For example, a white doctor might downplay a Black patient's complaints of pain after surgery due to subconscious, inherited stereotypes about the strength or pain tolerance of people of color, only to discover the patient is experiencing true discomfort.
Many people of color encounter barriers to accessing the healthcare they need due to lack of insurance (or insurance coverage that excludes fertility treatment). In addition to financial roadblocks, accessibility to quality reproductive care is often limited by:
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The long-held myth that Black women (and men) are "hyper-fertile" causes considerable harm, leading to a cascade of issues as a result.
Many people in the Black community believe in "praying your way" through difficult situations. And while it's wonderful to have faith, sometimes it's necessary to seek professional help. Trusting that a higher power will correct infertility leads some people to delay or avoid treatment altogether.
Black women are thought of as being incredibly strong, and we are. But when we are elevated to Superwoman status, and then need to take off our proverbial capes to ask for help, we are often judged harshly or perceived as weak.
Shame, guilt, or anxiety about how people in our community may react prevents or delays many women of color from seeking treatment for infertility. The stigma of mental illness is also a concern when addressing infertility.
Many people coping with infertility experience depression, anxiety and grief, and cultural norms can discourage people from sharing that they are struggling with their mental health.
Many people hesitate to talk about their personal experiences with infertility, which often leaves Black women with the impression that they are alone in their struggles or that infertility is a reflection of their character or a personal failing.
That's why sharing fertility stories is so important, especially in communities of color.
When it comes to maternal health, many women of color may lack insurance coverage or be afraid to advocate for themselves with their doctor. But the starkest evidence of the healthcare system failing people of color are Black maternal mortality rates in the United States, which are unnecessarily high.
Studies have shown that Black women are three times more likely to die from pregnancy-related causes than white women. Worse yet, even though there are multiple factors that contribute to this disparity, most of them are preventable.
These factors include access to quality healthcare, underlying chronic illnesses, and two of the most easily preventable - implicit bias and structural racism.
As a healthcare system, we need to focus on listening to the concerns of patients of color without allowing unconscious bias to play a role in our treatment decisions.
Below are just a few of the excellent organizations, books, and documentaries that are working to raise awareness of these racial disparities, increase access to quality fertility care, offer support, and improve health outcomes for Black women.
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There are many factors that play a role in the racial disparities in fertility and maternal healthcare. Some include distrust of medical providers, socioeconomic challenges, and at times, structural racism within the healthcare system.
Many Black women feel embarrassed talking openly about their fertility challenges, not knowing that there are many others struggling with the same issue. In many different cultures, women feel at fault or feel that their infertility is caused by something they may or may not be doing. They often feel as if they are the one to blame, and it shouldn’t be that way.
In vitro fertilization (IVF) and other fertility treatment options can be very expensive, which makes it exponentially harder for individuals with lower median household incomes to afford this path to parenthood.
Due to lower incomes in comparison to white and Asian couples, Black and Hispanic couples may have a hard time affording fertility care if they have to pay out-of-pocket.
So, what can we do? As providers, our job includes bridging the gap of distrust with the healthcare system amongst people of color and providing culturally competent care.
One important step towards doing this is increasing the diversity of providers within reproductive health specialties. This starts with improving education systems, providing opportunities for students of color to explore all of their career options, and encouraging curiosity from a young age.
Collectively, we must work to dismantle structural racism, educate ourselves, and listen to people of color. Only then will we start to make progress towards lessening racial disparities in fertility and maternal healthcare.
Sources & Further Learning
- How Structural Racism Works — Racist Policies as a Root Cause of U.S. Racial Health Inequities
- The Pervasive Issue of Racism and Its Impact on Infertility Patients
- Patient–Physician Relationships and Racial Disparities in the Quality of Health Care
- Infertility Knowledge and Treatment Beliefs Among African American Women in an Urban Community
- Increasing Racial and Ethnic Diversity Among Physicians: An Intervention to Address Health Disparities?
- The Pipeline Problem: Barriers to Access of Black Patients and Providers in Reproductive Medicine
- Implicit Bias and Racial Disparities in Health Care
- Tubal Factor Infertility, In Vitro Fertilization, and Racial Disparities: A Retrospective Cohort in Two US Clinics
- Infertility and Impaired Fecundity in the United States, 1982–2010
- Changing the Narrative, Starting With Us