Reproductive Injustice: Racism in Women’s Reproductive Health Care

By: Caroline McKenna


As June 2020 has been marked with milestones for the Black Lives Matter movement, we are reminded that systemic racism is not just present amongst the police force, but extends into education, employment, incarceration, housing, and healthcare. COVID-19 has highlighted pre-existing health inequities as BIPOC (black, indigenous, and people of colour) are disproportionately affected by the pandemic [1]. Though racism affects BIPOC across all aspects of health care, this article will focus on anti-Black and anti-Indigenous racism in women’s reproductive health care. 

Mistrust in the Health Care System:

Historical medical experimentation on BIPOC women continues to contribute to a general mistrust in health care providers (HCP). In the 1840s, Dr. J. Marion Sims conducted surgical experiments on Black enslaved women without anesthesia, though this was later offered to white women. Sims is referred to as the “Father of Gynecology” despite having no training in women’s health, and with little to no recognition of the countless Black women that suffered in his experiments [2]. In addition, the birth control pill was not developed solely to help women take control of their reproductive health, but also out of eugenics, a theory that “undesirable” populations could be reduced or eliminated by controlling their breeding. Clinical trials were conducted on Puerto Rican women who were given an extremely high dose of progesterone and told it would prevent pregnancy, but not that they were part of a clinical trial [3]. Severe side effects like depression and blood clots were common and three women died. In 1942, Canadian government researchers visited remote reserves in Manitoba and found extreme poverty and hunger. Rather than recommending increased support, the researchers used malnourished Indigenous people, including children in residential schools, for nutrition experiments where half were given essential vitamins and nutrients that were deliberately withheld from the other half [4]. More recently, in the 80s and 90s, John Philippe Rushton, a psychology professor at Western University, researched race and intelligence, arguing that Black people had smaller brains [5]. Though disproven, his work had a lasting impact on people’s implicit biases regarding Black people as inferior or simply different from the norm.

Abortion and Reproductive Justice:

When we think of reproductive health care, we often think of Reproductive Rights, defined by the reproductive rights movement of the 1970s that focused on pro-choice vs pro-life debates and the legalization of abortion. In 1994, the term Reproductive Justice was coined by a Black women’s caucus at a pro-choice conference in Chicago, later known as the SisterSong Women of Color Reproductive Justice Collective. Reproductive Justice extends beyond abortion legalization, recognizing that the intersections of race, class, and gender impede reproductive freedom when options are limited by oppressive circumstances or lack of access [6]. Reproductive Justice notes that “as Indigenous women and women of color it is important to fight equally for (1) the right to have a child; (2) the right not to have a child; and (3) the right to parent the children we have, as well as to control our birthing options, such as midwifery” [6].

Black and Indigenous Reproductive Health:

While the pro-choice movement has been a priority in white feminism, reproductive care goes beyond abortion access. What didn’t make the priority list was maternal health care – where quality, accessible, and culturally appropriate care is often limited for Black and Indigenous women. In the US, maternal mortality in Black women is three to four times higher than the white population [7], and Black infant mortality is two times higher [8] than their white counterparts, even among women with higher education and socioeconomic status. Unfortunately, Canada does not collect race-based data so it is unclear what these figures look like in Canada [9], [10]. However, a Canadian study found that Black women have significantly higher rates of premature births than white women, echoing trends in the US [11]. Moreover, Black women are three times more likely to have fibroids than white women [12], more likely to have endometriosis yet less likely to be diagnosed [13], and less likely to be screened for cervical cancer [9]. 

Similarly, maternal mortality in Indigenous women in Canada is two times higher compared to the general population [14], [15], and infant mortality rates are over two times higher in Indigenous infants than non-Indigenous infants [16]. Indigenous women also experience a disproportionately high rate of sexually transmitted infections, high-risk pregnancies, preterm deliveries, sexual violence, post-partum depression, and cervical cancer [17]. Poor health outcomes among this population are exacerbated by inadequate access to health and social services due to colonization, including structural barriers, racist and oppressive policies, intergenerational trauma, and complex social determinants of health [18]. This is further compounded by lack of access in remote areas that separates women from their communities during birth, severe underrepresentation of Indigenous people in the medical profession, and a lack of culturally appropriate care.  

So why are reproductive health outcomes so poor in these populations? Black and Indigenous women experience dangerous racism in the healthcare system. Research shows that medical personnel implicitly assume that Black people feel less pain than white people [19]. Another study found that HCPs are more likely to believe Black people are lying or exaggerating their symptoms [20], [21]. In addition, stereotypes of ‘unwed Black mothers’ taking advantage of social programs, and of Black men being ‘reckless baby daddies’, put Black people at risk of child apprehension and being denied assistance [22]. Racism in obstetrics plays a role in birth outcomes like complications, maternal mortality, and infant mortality [23], [24]. Even world famous tennis star Serena Williams has spoken out about her harrowing post-partum experience when her health care team didn’t take her pain seriously [25]. Similarly, when Patrisse Cullors, a co-founder of the Black Lives Matter movement, had an emergency C-section in 2016, she said the surgeon “never explained what he was doing to [her]” and “[her] mother basically had to scream at the doctors to give [her] the proper pain meds” [26]. A study found that negative birthing experiences among Indigenous women included experiences of racism, cultural insensitivity, and limited control over their care [27], [28]. Another study involving family medicine residents found that the majority were not educated on Canadian Indigenous history and, although willing, felt unprepared to work with Indigenous patients [29]. 

Forced Sterilization of Indigenous Women:

Coerced sterilization of Indigenous women is a shameful part of Canada’s history and continues today. In Saskatchewan, sixty Indigenous women are filing a class action lawsuit for tubal ligations done without their consent or after coercion from HCPs, between 1990 and 2017 [30].Some were pushed into signing consent forms during active labour or on operating tables, being told they “could not leave until their tubes were tied, cut or cauterized,” or that “they would not see their baby until they agreed” [31]. Karen Stote, author of An Act of Genocide: Colonialism and the Sterilization of Aboriginal Women states: “Imposing measures to prevent births within a group falls under the internationally accepted definition of genocide.” The practice is riddled with colonial undertones, under the guise of ‘wanting what’s best for women with several children who are at risk of poverty’, disregarding that it is not uncommon for Indigenous women to have many children and for grandparents to help with child care [32]. There is a similar history of sterilization abuse in Black, Puerto Rican, and Indigenous women in the US [33].

Recommendations for Health Care Providers:

While racism in reproductive health care is systemic, thus requiring systemic solutions, non-Black and non-Indigenous health care providers can also take steps to ensure they provide anti-racist care on an individual level. A few recommendations by The People Project [22]include: 

1) Educating yourself on clinical signs and symptoms in different populations (ex. recognizing jaundice, rashes, inflammation, bruising on darker skin), 

2) Educating yourself about the different ways people communicate pain or symptoms across cultures, and using pain assessment methods that recognize biases affecting communities of colour, 

3) Recognizing that common language like “let’s try this [treatment]” and rushing through appointments can raise fear of experimentation or discrimination, and actively building trust by giving explanations, encouraging participation in treatment plans, and addressing questions/concerns, 

4) Never assuming a patient’s pregnancy intentions or family structure, 

5) Being aware that some patients may be sick for longer due to factors like financial issues or unsafe housing, 

6) Recruiting and retaining HCPs who are Black or Indigenous as this may increase patient compliance and reduce drop-out rates [34]. 

Systemic solutions include working with members of Black and Indigenous communities to implement culturally appropriate care, collecting race-based data to better understand health disparities, implementing policies to improve representation of Black and Indigenous people in medicine and nursing, and more.

It is crucial to understand the historical context and the harmful, persistent stereotypes that depict BIPOC as deviations from the norm (the ‘white norm’), contributing to dangerous implicit biases in health care. To this day, these biases have a profound impact. Advocating for Black and Indigenous health and lives is more urgent than ever.

References:

[1]           O. Bowden and P. Chain, “Black neighbourhoods in Toronto are hit hardest by COVID-19 — and it’s ‘anchored in racism’: experts,” Global News, 2020.

[2]           S. Zhang, “The Surgeon Who Experimented on Slaves,” The Atlantic, 2018. .

[3]           E. Blakemore, “The First Birth Control Pill Used Puerto Rican Women as Guinea Pigs,” History, 2018. [Online]. Available: https://www.history.com/news/birth-control-pill-history-puerto-rico-enovid.

[4]           The Canadian Press, “Hungry aboriginal people used in bureaucrats’ experiments,” CBC News, 2013.

[5]           K. Edwards, “The time Western allowed academic freedom to go too far,” Western Gazette, 2019. [Online]. Available: https://westerngazette.ca/opinion/the-time-western-allowed-academic-freedom-to-go-too-far/article_7d54033a-2757-11e9-83c6-0fdae69d0a52.html.

[6]           L. J. Ross, “Understanding Reproductive Justice,” Atlanta, 2006.

[7]           CDC, “Vital Signs: Pregnancy-Related Deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013–2017,” 2019.

[8]           CDC, “Infant Mortality,” 2019.

[9]           G. Giorday, “Lack of health data hurting Black Canadian women, U of T researchers find,” U of T News, 2019. [Online]. Available: https://www.utoronto.ca/news/lack-health-data-hurting-black-canadian-women-u-t-researchers-find.

[10]        E. E. Martis, “Why Black Women Fear For Their Lives In The Delivery Room,” Huff Post, 2020. [Online]. Available: https://www.huffingtonpost.ca/entry/black-maternal-health-canada_ca_5ed90ae3c5b685164f2eab93.

[11]        B. McKinnon, S. Yang, M. S. Kramer, T. Bushnik, A. J. Sheppard, and J. S. Kaufman, “Comparison of black–white disparities in preterm birth between Canada and the United States,” CMAJ, vol. 188, no. 1, 2016.

[12]        Canadian Women’s Health Network, “Fibroids,” Canadian Women’s Health Network, 2012. [Online]. Available: http://www.cwhn.ca/en/node/40783. [Accessed: 12-Jun-2020].

[13]        O. Bougie, M. . Yap, L. Sikora, T. Flaxman, and S. Singh, “Influence of race/ethnicity on prevalence and presentation of endometriosis: a systematic review and meta‐analysis,” BJOG, vol. 126, no. 9, 2019.

[14]        Z. Luo, S. Senecal, and F. Simonet, “Birth outcomes in the Inuit-inhabited areas of Canada (Research),” CMAJ, vol. 182, pp. 235–242, 2010.

[15]        A. Oliveira, S. Kalra, and G. Wahi, “Maternal and new-born health profile in a first nations community in Canada,” J. Obstet. Gynaecol. Canada, vol. 35, pp. 905–913, 2013.

[16]        A. J. Sheppard et al., “Birth outcomes among First Nations, Inuit and Métis populations,” 2017.

[17]        M. Stout, K. GD, and R. Stout, “Aboriginal women’s health research synthesis project final report,” 2001.

[18]        First Nations Centre, “First Nations regional longitudinal health survey (RHS) 2002/2003: results for adults, youth and children living in First Nations communities,” Ottawa, 2005.

[19]        S. Trawalter, K. M. Hoffman, and A. Waytz, “Racial Bias in Perceptions of Others’ Pain,” PLoS One, vol. 11, no. 3, 2012.

[20]        J. A. Sabin, B. A. Nosek, A. G. Greenwald, and F. P. Rivara, “Physicians’ Implicit and Explicit Attitudes About Race by MD Race, Ethnicity, and Gender,” J Heal. Care Poor Underserved, vol. 20, no. 3, pp. 896–913, 2009.

[21]        J. M. Pines, R. Localio, and J. E. Hollander, “Racial Disparities in Emergency Department Length of Stay for Admitted Patients in the United States,” Acad Emerg Med, vol. 16, no. 5, pp. 403–10, 2009.

[22]        The People Project, “WORKING WITH PEOPLE AND COMMUNITIES OF COLOUR,” Action Canada for Sexual Health & Rights. [Online]. Available: https://www.srhweek.ca/providers/people-and-communities/people-of-colour/. [Accessed: 09-Jun-2020].

[23]        D.-A. Davis, “Obstetric Racism: The Racial Politics of Pregnancy, Labor, and Birthing,” Med. Anthropol., vol. 38, no. 7, 2018.

[24]        R. Chatterjee and R. Davis, “How Racism May Cause Black Mothers To Suffer The Death Of Their Infants,” NPR, 2017. [Online]. Available: https://www.npr.org/sections/health-shots/2017/12/20/570777510/how-racism-may-cause-black-mothers-to-suffer-the-death-of-their-infants. [Accessed: 12-Jun-2020].

[25]        TheGrio, “Serena Williams saved her own damn life after giving birth because apparently that’s what black women have to do,” The Grio, 2018. [Online]. Available: https://thegrio.com/2018/01/11/serena-williams-pregnancy-scare/. [Accessed: 12-Jun-2020].

[26]        N. Martin, “Black Mothers Keep Dying After Giving Birth. Shalon Irving’s Story Explains Why,” NPR, 2017. [Online]. Available: https://www.npr.org/2017/12/07/568948782/black-mothers-keep-dying-after-giving-birth-shalon-irvings-story-explains-why. [Accessed: 12-Jun-2020].

[27]        T. O’Driscoll, L. Kelly, and L. Payne, “Delivering away from home: The perinatal experiences of First Nations women in northwestern Ontario,” Can. J. Rural Med., vol. 16, pp. 126–130, 2011.

[28]        J. Kornelsen, A. Kotaska, and P. Waterfall, “The geography of belonging: The experience of birthing at home for First Nations women,” Health Place, vol. 16, pp. 638–645, 2010.

[29]        S. Sharma et al., “Canadian Indigenous Womens Perspectives of Maternal Health and Health Care Services: A Systematic Review,” Divers. Equal. Heal. Care, vol. 13, no. 5, 2016.

[30]        K. Kirkup, “Indigenous women coerced into sterilizations across Canada: senator,” CBC, 2018.

[31]        C. Radio, “Indigenous women kept from seeing their newborn babies until agreeing to sterilization, says lawyer,” CBC, 2018.

[32]        N. Post, “Saskatoon Health Region apologizes after aboriginal women felt pressured by staff to have tubes tied,” National Post, 2015. .

[33]        K. Kraze, “History of Forced Sterilization and Current U.S. Abuses,” Our Bodies Ourselves, 2014. [Online]. Available: https://www.ourbodiesourselves.org/book-excerpts/health-article/forced-sterilization/.

[34]        M. Alsan, O. Garrick, and G. C. Graziani, “Does Diversity Matter for Health? Experimental Evidence from Oakland,” Am. Econ. Rev., vol. 109, no. 12, pp. 4071–4111, 2019.

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