This information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
The Committee on Health Care for Underserved Women wishes to thank Raymond L. Cox, MD, MBA, for his invaluable assistance in the development of this document.
ABSTRACT: Significant racial and ethnic disparities exist in women's health. These health disparities largely result from differences in socioeconomic status and insurance status. Although many disparities diminish after taking these factors into account, some remain because of health care system-level, patient-level, and provider-level factors. The American College of Obstetricians and Gynecologists strongly supports the elimination of racial and ethnic disparities in the health and the health care of women. Health professionals are encouraged to engage in activities to help achieve this goal.
Health disparities can be defined as "differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States" (1). These differences can be assessed according to a variety of factors including gender, race or ethnicity, education, income, disability, geographic location, or sexual orientation (2). Although significant health disparities occur between men and women and among certain groups of women based on the factors mentioned previously, disparities are most likely to be experienced by women who are members of racial and ethnic minority groups. For example, disease and premature death occur disproportionately in minority women compared with non-Hispanic white women (3).
Approximately 44 million women in the United States, nearly one third of all women in this country, are members of racial and ethnic minority groups. African-American women and women of Hispanic origin together comprise roughly one quarter of the total population of U.S. women (4). The Hispanic population accounted for 22% of the 4 million births in the United States in 2003 (5). The largest segment of the immigrant population in the United States is from Latin America (6).
It is important to note that race and ethnicity are primarily social characteristics much more than they are biologic categories. However, race and ethnicity can provide useful information to women's health care providers about environmental, cultural, behavioral, and medical factors that may affect their patients' health. Also, the frequency of certain genetic variations may differ between racial or ethnic groups. For instance, there is an increased frequency of mutations for certain genetic diseases, such as Tay-Sachs disease, in individuals of Ashkenzic Jewish descent. These differences in the frequency of genetic variations generally are related to a common ancestral lineage (founder effect).
Genetic polymorphisms associated with increased susceptibility to disease also may vary in frequency in different racial and ethnic groups (7). Another consideration is the issue of gene-environment interaction. Genetic variations, even those that do not vary in frequency among racial or ethnic groups, may enhance susceptibility to an environmental exposure that occurs more frequently in a particular racial or ethnic group. Thus, although race and ethnicity are primarily social constructs, the impact of common ancestral lineage on the segregation and frequency of genetic variations in combination with the influence of cultural factors on environmental exposures cannot be ignored. All of these factors should be considered when trying to elucidate the multifactorial causes of health disparities.
Examples of Racial and Ethnic Health Disparities Among Women
- During 1991–1995, heart disease death rates remained the highest for African-American women, followed by white, American Indian/ Alaskan Native, and Asian/Pacific Islander women, with more than a twofold difference between the lowest and highest rates (8).
- Asian/Pacific Islander women, especially those who are Vietnamese; black women; and Hispanic white women have higher incidence rates of invasive cervical cancer than non- Hispanic white women (9, 10). Cervical cancer mortality rates are higher among American Indian/Alaskan Natives than among all racial and ethnic populations (3.7 per 100,000 population and 2.6 per 100,000 population, respectively) despite lower incidence (11).
- When compared with white women, black women have a higher mortality rate (34.7 per 100,000 compared with 25.9 per 100,000) for breast cancer despite a lower breast cancer incidence rate (10).
- Seventy-eight percent of the female population with acquired immunodeficiency syndrome (AIDS) is African American or Hispanic. Although American Indian/Alaskan Native women have a lower annual rate of new AIDS cases (4.8 per 100,000) than non-Hispanic black (50.2 per 100,000) and Hispanic (12.4 per 100,000) women, the rate is still more than twice the rate for non-Hispanic white women (2.0 per 100,000) (12).
- Non-Hispanic black and some Hispanic populations have preterm births at rates 60% and 27% higher, respectively, than the rate for non- Hispanic white women (13).
- African-American women have higher infant, fetal, and perinatal mortality rates than white women (14) (see Table 1).
- Although maternal mortality ratios for all ethnic groups have declined over the past half century, racial and ethnic disparities in maternal mortality have actually increased (15, 16). African- American women are three to six times more likely to have a pregnancy-related death than white women (16).
Understanding the Causes of Health Disparities
Many health disparities are directly related to inequities in income, housing, safety, education, and job opportunities; they largely result from differences in socioeconomic status and insurance status. Although many disparities diminish after taking these factors into account, some remain because of health care system-level, patient-level, and provider level factors (17).
The current U.S. health care financing paradigm inadvertently may contribute to disparities in health outcomes. The United States is the only developed country that does not extend health care as a right of citizenship. In the United States, health care is driven by market forces; the ultimate goal of the health care business is to maximize profit. For these reasons, this health care system contributes to a lack of access for citizens who are either uninsured or underinsured. The varying geographic availability of health care institutions also may contribute to racial and ethnic disparities in health care.
|Table 1. Infant, Fetal, and Perinatal Mortality by Race of Mother
|Race of Mother
||Infant Mortality Rate
||Fetal Mortality Rate
||Perinatal Mortality Rate
|Black or African American
|National Center for Health Statistics. Health, United States, 2004: with chartbook on trends in the health of Americans. Hyattsville (MD): NCHS; 2004. Available at: http://www.cdc.gov/nchs/data/hus/hus04.pdf. Retrieved June 23, 2005.
Access to health insurance coverage and care and utilization of care is significantly different for minority women. The following examples illustrate this point:
- Hispanic and African-American women are more likely to be uninsured than white women. In 2001, 16% of white women, 20% of African- American women, and 37% of Hispanic women 18–64 years of age were uninsured (18).
- Asian-American and Hispanic women are most likely to have not received preventive care in the past year. In 1998, 29% of Asian-American women and 21% of Hispanic women received no preventive services in the previous year compared with 16% of white women and 7% of African-American women. (19).
- The proportion of Asian-American women obtaining Pap tests was considerably lower than that for white women. Only approximately one half (49%) of Asian-American women reported receiving a Pap test in the previous year compared with 64% of white women (19).
- Non-Hispanic black, Hispanic, and American Indian women are more than twice as likely as non-Hispanic white women to begin prenatal care in the third trimester or not at all (5).
Evidence suggests that factors such as stereotyping and prejudice on the part of health care providers may contribute to racial and ethnic disparities in health (17). Additionally, cultural differences between the health care provider and patient can cause communication problems between the patient and the provider and can lead to an inaccurate understanding of the patient's symptoms. Ambiguities between health care providers' and patients' understanding and interpretation of information may contribute to disparities in care (17). For example, language and literacy barriers interfere with physician–patient communication and can contribute to culturally derived mistrust of the health care system and to reduced adherence to health care provider recommendations. Use of traditional or folk remedies can interfere with science-based treatments. There also are lifestyle risk factors, such as unhealthy diets, low levels of physical activity, and alcohol and tobacco use, which contribute to morbidity and mortality and are more prevalent among certain populations (3).
The American College of Obstetricians and Gynecologists strongly supports the elimination of racial and ethnic disparities in women's health and health care as well as gender disparities in health and health care. The elimination of disparities in women's health and health care requires a comprehensive, multilevel strategy that involves all members of society. Our goal as health care providers and leaders must be to optimize individuals' health status and the quality of health care. We encourage health professionals to engage in the following activities:
- Advocate for universal access to basic affordable health care (20).
- Improve cultural competency in the physician– patient relationship and engage in cross-cultural educational activities to improve communication and language skills (21).
- Use national best practice guidelines to reduce unintended variation in health care outcomes by gender, race, and ethnicity.
- Provide high quality, compassionate, and ethically sound health care services to all. Engage in dialogue with patients to determine their care expectations, and counsel patients regarding the benefits of preventive health care and early screening, intervention, and treatment.
- Advocate for increased public awareness of the benefits of preventive health care and early screening and intervention.
- Encourage and become active in recruiting minorities to the health professions.
- Advocate for improved access to programs that develop fluency in English among non-English speaking populations.
- Acquire team-building skills to help attract and retain qualified nurses and other health professionals for provision of quality services to underserved women.
- Conduct research to determine causes of health disparities and develop and evaluate interventions to address these causes.
- Advocate for the continued collection of race based data which is important in understanding disparities. Advocate for increased funding for this research.
- Increase training of health care providers about racial, ethnic, and gender disparities in health and health care.
- Support safety net providers, including public health systems, urban academic centers, and other health care delivery systems that are more likely to provide health care to minority populations.
- Fauci AS. Slideshow: The NIH Strategic Plan to Address Health Disparities. Bethesda (MD): National Institutes of Allergy and Infectious Diseases; 2000. Available at: http://www.niaid.nih.gov/director/healthdis.htm. Retrieved June 23, 2005.
- U.S. Department of Health and Human Services. Healthy people 2010: understanding and improving health. 2nd ed. Washington, DC: U.S. Government Printing Office; 2000. Available at: http://www.healthypeople.gov/Document/pdf/uih/2010uih.pdf. Retrieved June 23, 2005.
- Clark A, Fong C, Romans M. Health disparities among U.S. women of color: an overview. Washington, DC: The Jacobs Institute of Women's Health; 2002.
- U.S. Bureau of the Census. Population by age, sex, race, and Hispanic or Latino origin for the United States: 2000(PHC-T-9). Washington, DC: The Bureau; 2001. Available at: http://www.census.gov/population/www/cen2000/phc-t9.html. Retrieved June 23, 2005.
- Hamilton BE, Martin JA, Sutton PD. Births: preliminary data for 2003. Natl Vital Stat Rep 2004;53(9):1–17.
- Larsen LJ. The foreign-born population in the United States: 2003: population characteristics. Current Population Reports, P20-539. Washington, DC: US Census Bureau; 2004. Available at: http://www.census.gov/prod/2004pubs/p20–551.pdf. Retrieved June 23, 2005.
- Romero R, Kuivaniemi H, Tromp G, Olson J. The design, execution, and interpretation of genetic association studies to decipher complex diseases. Am J Obstet Gynecol 2002;187:1299–312.
- Casper ML, Barnett E, Halverson JA, Elmes GA, Braham VE, Majeed ZA, et al. Racial and ethnic disparities in heart disease among women. In: Women and heart disease: an atlas of racial and ethnic disparities in mortality. 2nd ed. Atlanta (GA): Centers for Disease Control and Prevention; Morgantown (WV):West Virginia University, Office for Social Environment and Health Research; 2000. Available at: ftp://ftp.cdc.gov/pub/Publications/ womens_atlas/00-atlas-all.pdf. Retrieved June 22, 2005. p. 19–24.
- Satcher D. American women and health disparities [editorial]. J Am Med Womens Assoc 2001;56:131–2, 160.
- Ries LA, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, et al., editors. SEER cancer statistics review, 1975–2002. Bethesda (MD): National Cancer Institute; 2005. Available at: http://seer.cancer.gov/csr/1975_2002. Retrieved June 23, 2005.
- Cancer mortality among American Indians and Alaska Natives—United States, 1994–1998. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep 2003;52:704–7.
- Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2003;15:1–46. Available at: http://www.cdc.gov/hiv/stats/2003SurveillanceReport.pdf. Retrieved June 22, 2005.
- Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: final data for 2002. Natl Vital Stat Rep 2003;52(10):1–113.
- National Center for Health Statistics. Health, United States, 2004: with chartbook on trends in the health of Americans. Hyattsville (MD): NCHS; 2004. Available at: http://www.cdc.gov/nchs/data/hus/hus04.pdf. Retrieved June 23, 2005.
- Differences in maternal mortality among black and white women—United States, 1990. MMWR Morb Mortal Wkly Rep 1995;44:6–7, 13–4.
- State-specific maternal mortality among black and white women—United States, 1987–1996. MMWR Morb Mortal Wkly Rep 1999;48:492–6.
- Institute of Medicine (US). Unequal treatment: confronting racial and ethnic disparities in healthcare. Washington, DC: The Institutes 2002.
- Kaiser Family Foundation. Racial and ethnic disparities in women's health coverage and access to care: findings from the 2001 Kaiser Women's Health Survey. Menlo Park (CA): KFF; 2004. Available at: http://www.kff.org/womenshealth/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=33087. Retrieved June 23, 2005.
- Collins KS, Schoen C, Joseph S, Duchon L, Simantov E, Yellowitz M. Health concerns across a woman's lifespan: The Commonwealth Fund 1998 Survey of Women's Health. New York (NY): The Commonwealth Fund; 1999.
- The uninsured. ACOG Committee Opinion No. 308. American College of Obstetricians and Gynecologists. Obstet Gynecol 2004;104:1471–4.
- American College of Obstetricians and Gynecologists. Cultural competency, sensitivity and awareness in the delivery of health care. In: Special issues in women's health. Washington, DC: ACOG; 2005. p. 11–20.
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Racial and ethnic disparities in women's health. ACOG Committee Opinion No. 317. American College of Obstetricians and Gynecologists. Obstet Gynecol 2005;106:889-92.