Obstetrics

Topic & Clinical Relevance

• Postpartum hemorrhage (PPH), a blood loss after birth of >1000mL, is a leading cause of death bothworldwide and in the U.S. The most common cause of PPH is uterine atony, in which the uterinemuscles do not contract adequately after birth, which leads to a lack of compression of the blood vessels, resulting in significant bleeding (Oyelese & Ananth, 2020; Bateman et al., 2010).
• Racial and ethnic disparities persist in atonic PPH and severe atonic PPH despite adjustment for numerous potential explanatory variables. Literature demonstrates that Hispanic and Asian/Pacific Islander birthing people have higher rates of PPH. While Black/African American birthing people have a similar or even slightly lower rate of PPH overall in these studies, they experience a higher rate of severe PPH that result in blood transfusions and hysterectomy as a measure to stop the bleeding (Bryant et al., 2012; Gyamfi-Bannerman et al., 2018; Wetta et al., 2013).
• Identifying risk factors for severe PPH in advance and being prepared for and ready to treat heavy bleeding are key interventions to reducing morbidity and mortality due to PPH. Widely used models to identify those at high risk such as the California Maternal Quality Care Collaborative (CMQCC) OB Hemorrhage Toolkit V3.0 Errata 7.18.22 | California Maternal Quality Care Collaborative have historically used Asian race and Hispanic ethnicity, but not Black race, as independent risk factors for PPH. Many hospitals may still be using these older tools, which lead to differential risk stratification and care based on race (Lagrew et al., 2022).

Historical Roots

• Black, Indigenous, and other birthing people of color experience high rates of maternal morbidity and mortality (Artiga, 2020). This phenomenon has often been misattributed to genetics and culture. Multiple organizations are working toward eliminating these disparities and inequities by centering those most impacted, including Every Mother Counts and National Birth Equity Collaborative.
• Race and ethnic categories are not discrete biological groups. The U.S. Office of Management and Budget, whose definition is used on the U.S. Census, defines "Hispanic or Latino" as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race (U.S. Census Bureau, 2022). Hispanic ethnicity is thus a broad category that encompasses a wide range of ancestries and races. Additionally, Asian/Pacific Islander race includes individuals from countries and ancestral origins as different as India, the Philippines, Japan, and Cambodia (U.S. Census Bureau, 2022). Racial and ethnic groupings are thus poor proximate indicators for genetic ancestry.

Frequent Misconceptions

• “Higher rates of PPH in Hispanic and Asian Pacific Islander birthing people, and higher rates of severe PPH in Black birthing people, represent race-based, biological differences in birthing risk”
  • Review articles from electronic health record data describe higher rates of PPH in patients with Asian/Pacific Islander race and Hispanic ethnicity, and higher rates of severe PPH requiring transfusion and hysterectomy in non-Hispanic Black patients (Bryant et al., 2012; Gyamfi-Bannerman et al., 2018; Wetta et al., 2013). In the papers, authors explicitly state that the higher rates of PPH in Hispanic and Asian Pacific Islander patients may indicate a genetic or biological cause.
  • Given that these articles were primarily retrospective chart reviews, it is unclear how racial and ethnic data points were collected and entered, rendering these categorical associations unreliable.
  • Even if the racial and ethnic data points collected were an accurate approximation of an individual’s self-identified race and ethnicity, neither race nor ethnicity are an accurate predictor of genetic makeup (Cerdeña, 2022).

How Adjustment Contributes to Health Inequity

• Using a PPH risk assessment tool that includes Asian race and Hispanic ethnicity as biological markers for PPH may lead to Asian and Hispanic patients having higher PPH risk scores and an increase in the rate of intervention, including blood draws, administration of additional medications, and reduced access to birthing options that are restricted to “low risk” birthing patients.
• Black patients experience severe PPH resulting in transfusion and hysterectomy at higher rates. If using a risk scoring system like the one above, clinicians may develop a false sense of security of lower risk of PPH, delayed diagnosis, and worse outcomes related to PPH.

Possible Solutions

• We should acknowledge that multiple studies have found increased frequency of significant maternal morbidities among specific racial and ethnic groups (Asian or Hispanic), including PPH, and we should use this increased rate to guide our caution in caring for patients from these backgrounds in order to not underdiagnose or undertreat them.
• We must also acknowledge that it is possible that Black patients are not actually experiencing a lower rate of PPH, but that they are receiving a delayed or under-diagnosis, such that once PPH is recognized, it is severe and more likely to require transfusions and dramatic measures to stop bleeding such as a hysterectomy.
• Race and ethnicity should not be used as a proxy for biological risk factors but as markers of increased risk of misdiagnosis and exposure to the effects of clinician bias.

Takeaway Points

• Racial and ethnic disparities exist for postpartum hemorrhage, with Hispanic and Asian Pacific Islander birthing people having higher overall rates of PPH, and non-Hispanic Black individuals having higher rates of severe PPH, but these inequities are not due to inherent biological or genetic differences.
• Clinicians should use utilize risk assessment tools using demonstrated biological, perinatal, and obstetric conditions that increase the risk of atonic PPH, such as the CMQCC updated hemorrhage toolkit (Lagrew, 2022) and take adequate measures (e.g., active management of the 3rd stage of labor, having uterotonics readily available) to reduce the incidence and consequences of PPH in all birthing people.

Sources

To view all cited sources, please read our one-pager.

Topic & Clinical Relevance

• Long Acting Reversible Contraceptive (LARC) methods refer to intrauterine devices (IUDs) and implants. These methods of birth control provide highly effective birth control, without the patient needing to remember to take a daily pill, schedule a monthly appointment for a shot, or consistently use condoms.
• Healthcare providers regularly counsel patients on contraceptive options, thereby playing a role in steering them toward or away from LARCs as a method of contraception.
• Studies have shown that providers vary their contraceptive recommendations to individuals based on race, ethnicity, and socioeconomic status (SES), even when clinical factors between individuals are identical (Dehlendorf et al. 2010).
• Unchecked enthusiasm for LARC methods may lead to promoting their use among populations perceived as "high risk," which may paradoxically undermine reproductive autonomy, particularly in non-white, low-SES patients.

Historical Roots

• BThere is a long-standing history of reproductive oppression in the U.S. targeted at low-income people and people of color. Efforts to reduce fertility and childbearing in these groups are well documented, even in recent years. These groups continue to experience racial discrimination in family planning settings.
• Perhaps the most egregious example of this has been a history of coerced and forced sterilizations which have been targeted towards people of color and those of lower SES (Stern, 2005; Stern, 2020). As recently as 2013, the Center for Investigating Reporting discovered that women continued to be sterilized without consent in the California prison system (Johnson, 2013).
• U.S. federal policy continues to allow individual states to cap welfare benefits based on family size, leveraging restriction of public benefits as a means of discouraging fertility amongst people of lower SES (National Conference of State Legislatures, 2011). Some states have taken this as far as trying to incentivize or require LARC as a prerequisite for obtaining welfare assistance (Jekanowski, 2018).
• Previous research has shown that family planning discrimination extends to the prescribing practices of individual physicians. Black and Latinx patients are more likely than white women to be advised to restrict their childbearing (Downing et al., 2007). Clinicians are more likely to recommend IUDs to low-SES black and Latinx patients than low-SES white patients (Dehlendorf et al., 2010).

Frequent Misconceptions

• “LARCs are the best form of birth control, so should be offered as first line treatment to all patients”
  • “For some women, optimal control may mean choosing a method that will almost never fail. For others, optimal control may mean choosing a method that can be started or discontinued as they choose, without the assistance of a healthcare provider. For still others, control might relate to the effect of a method on the menstrual cycle…For a multitude of reasons, even with perfect knowledge and no barriers to access, many women will still not choose LARC methods. And as long as a woman's choice is based on accurate information and a good understanding of her own priorities, htat decision should be supported as a positive outcome" (Gomez et al., 2014).

• "'High risk' patients should all be counseled to receive LARCs, since they are most likely to benefit from long-term contraception."
  • Targeted approaches to LARC promotion, guided by population-level statistical data, runs the risk of imposing statistical discrimination, where epidemiologic data replaces consideration of a patient's unique history, preferences, and priorities (Gomez et al., 2014).

• “LARCs are easily reversible so there is no downside to implanting them.”
  • Insurance does not always cover removal of LARCs, particularly if the patient seeks removal prior to the lifespan of the contraceptive device.
  • For some patients, needing to return to a healthcare provider, who may not be a trusted figure, can serve as a barrier to removal. Patients may also receive pressure from a provider to keep their LARC, even if they have expressed that they no longer want it (Higgins, et al., 2016).

How Contraceptive Counseling Differences Contribute to Health Inequity

• The goal of contraception should be to increase autonomy and choice for patients. By promoting LARCs at increased rates to non-white, low-SES patients, healthcare providers may paradoxially restrict options and limit autonomy in these patients (Gomez et al., 2014).
• Differences in contraceptive counseling may serve to further undermine trust between providers and patients, which contributes to patient disengagement from the medical system. This may, in turn, have negative implications for patients in other aspects of their healthcare (Higgins, et al., 2016).

Possible Solutions

• Patient-centered care should be prioritized above all else. Health care providers should determine the patient's priorities for contraceptive methods before recommending a specific method.
• Investment in strategies to train and support health care providers from lower SES backgrounds and health care providers of color can reduce the risk of bias in healthcare delivery. Patients report higher levels of trust and communication when there is racial concordance between providers and patients.
• Removal of cost barriers to LARC implantation and removal should be prioritized. Individual autonomy in contraceptive decisions is optimized when patients feel confident that they can both implant and remove their contraceptive method without financial barriers.

Takeaway Points

• Studies have shown that providers vary their contraceptive recommendations to individuals who differ on no clinically relevant variables, but only on race, ethnicity, and socioeconomic status (SES).
• There is a long-standing history of reproductive oppression targeted at low-income people and people of color. Health care providers must be educated and aware of this history in order to appropriately promote LARC methods when counseling their patients.
• All contraceptive counseling– but especially that aimed at providing care for historically oppressed groups– should center patient preferences and concerns above all else.

Sources

To view all cited sources, please read our one-pager.

Topic & Clinical Relevance

• The Breast Cancer Risk Assessment Tool (BCRAT) created by the National Cancer Institute is commonly used to estimate the average woman’s 5-year and lifetime risk of development of invasive breast cancer. Risk estimates are often considered during shared decision-making regarding breast cancer screening.
• Race and ethnicity are included under the demographics section as qualitative risk factors affecting calculation of risk. Notably, “white race increases the risk of breast cancer”.
• Per the disclaimer provided by NCI: “The tool may underestimate risk in black women with previous biopsies and Hispanic women born outside the United States. Because data on American Indian/Alaska Native women are limited, their risk estimates are partly based on data for white women and may be inaccurate.”1
• Age-adjusted incidences of breast cancer for all minority groups were lower when compared to white women2. Minority women, particularly Black women, are more likely to present with cancers with unfavorable characteristics (eg. high grade, estrogen receptor negative) and have higher rates of mortality2,3.

Historical Roots

• The Breast Cancer Risk Assessment Tool (BCRAT) is based on a statistical model known as the Gail Model, named after Dr. Mitchell Gail, Senior Investigator in the Biostatistics Branch of the NCI Division of Cancer Epidemiology and Genetics.
• The data utilized to develop the model are summarized at the bottom of this article. White patients made up the vast majority of the sample population(280,000 White patients vs 3,244 black patients, 1,563 AAPI patients, and 2,497 Hispanic/Latinx patients).

Frequent Misconceptions

• “Black race is a biological factor associated with increased mortality from breast cancer.”
  • Mortality rates in the US for Black women were lower than for White women prior to 1980. In the 1980s, mammography screening and adjuvant endocrine therapy were widely implemented in the US. Racial disparity in outcomes can be associated with advancement in breast cancer management and differences in access to care.

How Adjustment Contributes to Health Inequity

• Models estimate the risk of being diagnosed with breast cancer rather than risk of mortality due to breast cancer. It does not address or provide information about outcomes of disease.
• The BCRAT estimates a lower risk of breast cancer development for Black women compared to white women, but this may lead to a false sense of security in clinical guidance given that Black women have higher mortality. This lower risk may influence individual patients’ decisions to delay initiation of mammographic screening, even though Black women tend to be diagnosed at a younger age compared to White women.

Possible Solutions

• On an individual level: Consider focusing on more individualized factors (eg. family history, age) in clinical decision-making regarding screening.
• On a systemic level: Include more racial and ethnic diversity in studies that are used to develop and validate risk assessment tools. Health care literacy for immigrant and minority populations/promotion of preventative care are also potential avenues to explore.

Takeaway Points

• Risk assessment tools estimate the risk of diagnosis of breast cancer, not morbidity/mortality.
• Access to preventative care resources may lead to underestimated risk for women of racial/ethnic minorities.

Sources

To view all cited sources, please read our one-pager.