Celebrating Black History Month reminds me of the rich legacy of African Americans and all people of African descent, not only in the United States, but world-wide.
To me, Black History Month is a time to celebrate the rights that Martin Luther King Jr and other trail blazers fought for. Rights which are central to who I am today; my education, my access to healthcare, and most importantly my ability to provide fertility care to people from all backgrounds.
Education and healthcare are both universally acknowledged as human rights, but despite how far we’ve come, they continue to be under siege in minority communities, with black women lagging far behind.
Although I am not an expert in education, it is because of my education as a reproductive endocrinologist that I am acutely aware of the disparities that exist in both access to fertility care and outcomes from fertility treatments in women of color.
Speaking of education, since the people most likely to have an employer benefit that covers fertility treatment tend to work in industries such as tech, finance or healthcare, it is hard to pretend that one’s education and subsequent employment as a result of said education, does not have a salient impact on their access to fertility treatments.
That being said, I wish equal access to fertility care meant equal outcomes, however this is not the case.
The unpleasant fact is that even when insurance coverage and household income are accounted for, disparities in outcomes from fertility treatment are still evident. As African American women, we are more likely than our white counterparts to discontinue treatment even when we have similar insurance coverage, and likelihood of success. This means that we are more likely to stop fertility treatment sooner than recommended and thus less likely to take a baby home at the end of the day (1,2).
Even when we stick it out and go through with fertility treatment, there is a disturbing trend of poorer outcomes. This is due to multiple factors including the fact that we are more likely to have medical conditions such as uterine fibroids and obesity which lead to decreased pregnancy and live-birth rates. We are also more likely to present for care at an older age, which leads to worse outcomes because age is the strongest predictor of pregnancy following fertility treatment (2).
However, even when we control for these factors we still have poorer outcomes. In light of these data, attributing the poorer outcomes in black women to the aforementioned factors alone, would not only be contrary to the data, but akin to willful ignorance. Other well described reasons for these outcomes include, the impact of systemic racism, the type of treatment received and dearth of good quality data on this issue (2). We now know that implicit bias plays a role not only in how we care for our patients as physicians, but in their treatment outcomes as well, and so even in healthcare representation matters (3,4).
However, hope is not lost. Steps can be taken and have been taken to improve access to fertility care and treatment outcomes among women of color. These include but are not limited to:
1. Expanding insurance coverage: Organizations such as Kindbody are leading the pack in expanding employer coverage of fertility benefits. This allows patients to present to care earlier and even more importantly to move more quickly to the most effective treatment to help them achieve a pregnancy without the encumbrance of cost.
2. Improve training on implicit bias and discrimination: The need for better training for providers from all backgrounds on implicit bias is urgent and necessary. Last year the America Board of Obstetrics and Gynecology (ABOG) had mandatory implicit bias training for all board certified OBGYNs. While this short video was a noteworthy step in the right direction, much more needs to be done in order to effect change.
3. Educating and empowering women about reproductive health: Lack of knowledge and empowerment play a role, and these are amplified when black female patients have experiences that reinforce a distrust of the medical system.
While the onus is on us as providers to create a comfortable environment, I also recommend seeking out reputable sources of information about fertility health such as www.reproductivefacts.org, www.https://resolve.org, or on the Kindbody blog page at https://kindbody.com/blog. Also, ask all your questions when you see your doctor and if they can’t all be addressed in a single visit, then you can always set up a follow up visit to address them. Kindbody will also be hosting a webinar on Thursday, February 24th on fertility and the black experience, and you can ask some of your questions then as well.
4. Dispelling the fertile black woman myth: I take this point very personally. As a black woman with diminished ovarian reserve and recurrent pregnancy loss, this pervasive image of the fertile black woman made me feel like a failure for not living up to a societal image of black women that was created for the explicit purpose of permitting exploitation of black women and eugenic practices of forced sterilization. As a result, it is my mission to ensure that all women are educated about their reproductive health in general and also about the issues that affect them on an individual level.
As black women we have spent too long being characterized, defined and explained away by people with no comprehension of our lived experience. As you celebrate Black History Month, alongside the listening to special podcast episodes, buying BHM apparel and themed Peloton rides, I also encourage you to take charge of your reproductive health and chart your fertility future.
References:
1. Bedrick, B.S., Anderson, K., Broughton, D.E., Hamilton, B. and Jungheim, E.S., 2019. Factors associated with early in vitro fertilization treatment discontinuation. Fertility and sterility, 112(1), pp.105-111.
2. Jackson-Bey, T., Morris, J., Jasper, E., Edwards, D.R.V., Thornton, K., Richard-Davis, G. and Plowden, T.C., 2021. Systematic review of racial and ethnic disparities in reproductive endocrinology and infertility: where do we stand today?. F&S Reviews, 2(3), pp.169-188.
3. Wallis, C.J., Jerath, A., Coburn, N., Klaassen, Z., Luckenbaugh, A.N., Magee, D.E., Hird, A.E., Armstrong, K., Ravi, B., Esnaola, N.F. and Guzman, J.C., 2022. Association of surgeon-patient sex concordance with postoperative outcomes. JAMA surgery, 157(2), pp.146-156.
4. Greenwood, B.N., Hardeman, R.R., Huang, L. and Sojourner, A., 2020. Physician–patient racial concordance and disparities in birthing mortality for newborns. Proceedings of the National Academy of Sciences, 117(35), pp.21194-21200.
