Narrative Review

Historical Primer on Obstetrics and

Gynecology Health Inequities in America
A Narrative Review of Four Events
Aisha Nnoli, MD, MPH

ied this ethos by obtaining a medical degree and a

Four historical events provide context for racial injustices
master’s degree in public health; working as a faculty
and inequities in medicine in the United States today: the
physician; and being a mother, wife, and veteran. I
invention of race as a social construct, enslavement in the
have achieved the American dream; however, as a
Americas, the legal doctrine of Partus sequitur ventrem,
and the American eugenics movement. This narrative
college-educated Black woman in America, my
review demonstrates how these race-based systems re- pregnancy-related mortality ratio is five times as high
sulted in stereotypes, myths, and biases against Black as that of my White colleagues and friends.2 Frances
individuals that contribute to health inequities today. M. Beal first described how intersections of oppression
Education on the effect of slavery in current health care shape the lived experience of Black women in Amer-
outcomes may prevent false explanations for inequities ica, which was formalized into the concept of intersec-
based on stereotypes and biases. These historical events tionality by Kimberlé Crenshaw.3,4 Intersectionality
validate the need for medicine to move away from prac- acknowledges the multiple identities of race, ethnicity,
ticing race-based medicine and instead aim to under- gender, sexual orientation, and socioeconomic status,
stand the intersectionality of sex, race, and other social “that intersect at the micro level of individual experi-
constructs in affecting the health of patients today. ence to reflect multiple interlocking systems of privi-
(Obstet Gynecol 2023;142:779–86) lege and oppression at the macro, social–structural
DOI: 10.1097/AOG.0000000000005331 level (eg, racism, sexism, heterosexism).”4–6 In this
context, it becomes clear that regardless of my work

T he American dream is, “the belief that America and accomplishments, my health outcomes are nega-
offers the opportunity to everyone of a good and tively affected by the deep-rooted systemic racism that
successful life achieved through hard work.”1 I embod- persists in American medicine.
Bigotry, “otherness,” and intersections of oppres-
From the MultiCare Obstetrics and Gynecology Associates, MultiCare Health sion have been part of my life experience. My first
Systems, and the Tacoma Family Medicine Residency Program and Rural Family recollection of being the recipient of bigotry was at
Medicine With Obstetrics, Tacoma, and the Department of Family Medicine,
University of Washington, Seattle, Washington.
age 10 during a playdate at my friend’s house. My
The author thanks the following individuals for their contributions: Deirdre
friend mentioned being scared of the untrained rott-
Cooper Owens, PhD, for her historical expertise, guidance, and mentorship; weiler her stepfather recently bought. As we headed
and Janelle Guirguis-Blake, MD, for her editorial expertise and critiques. to the kitchen, the rottweiler aggressively barked at us.
The author has confirmed compliance with the journal’s requirements for author- While we cowered in fear, her stepfather calmly sat at
ship. the kitchen table and stated, “We used to use dogs to
Corresponding author: Aisha Nnoli, MD, MPH, MultiCare Obstetrics and manage the slaves; that is why you are scared of that
Gynecology Associates, Tacoma, WA; [Link]@[Link].
dog.” Only after my friend pleaded to have the dog
Financial Disclosure
The author did not report any potential conflicts of interest.
returned outside did her stepfather comply. After hur-
rying away, my friend expressed her dismay. I felt
Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the terms of the Creative Com- dehumanized by a false belief that people who look
mons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC- like me are biologically fearful of dogs. My first expe-
ND), where it is permissible to download and share the work provided it is
rience of anti-Blackness and the gut punch that came
properly cited. The work cannot be changed in any way or used commercially
without permission from the journal. with feeling “othered” and “less than” taught me that
ISSN: 0029-7844/23 some do not see me for who I am. Throughout my

VOL. 142, NO. 4, OCTOBER 2023 OBSTETRICS & GYNECOLOGY 779

professional life, I continued feeling “othered” and [ies] groups of people by physical traits, appearance,
“less than” in various forms. or characteristics” and was invented during the Euro-
The example above highlights how systems of pean Enlightenment.9 In the late 17th and 18th cen-
oppression minimize, marginalize, and devalue indi- turies, European philosophers created a formalized
viduals. Renewed energy around racial injustice and racial hierarchy through the, “false notion that ‘White
inequity has created a space to understand how health people’ were inherently smarter, more capable, and
care systems perpetuate systems of oppression. His- more human than non-White people.”9 These ideals
torically, adverse maternal and infant health outcomes became justification for European colonization and
for Black patients were incorrectly attributed to the lucrative enslavement of African people in the
genetic and sociobehavioral factors while overlooking Americas.10–13
the larger systems and structures of oppression and The use of race to show biological differences in
discrimination that are root causes of reproductive medical research has supported the harmful practice
health disparities.7,8 of race-based medicine. An example of this is the
Four historical events provide context for current former race adjustment for the vaginal birth after
racial injustices and medical inequities in the United cesarean calculator.14–18 Higher rates of cesarean
States: the invention of race as a social construct, the births in Black individuals compared with White indi-
enslavement of African people, the legal doctrine of viduals were falsely attributed to, “a true biological
Partus sequitur ventrem, and the American eugenics difference in the ability of the fetus to tolerate
movement. This article serves as a historical summary labor.”18–20 This form of racism in obstetrics resulted
and foundation for personal realization, group dialog, in self-identified Black or Latinx individuals with half
and social growth. Further reading materials are the odds of a vaginal birth after cesarean compared
provided for reference (Table 1). with White individuals, likely leading to many unnec-
essary cesarean births.18 Another example of race-
17TH AND 18TH CENTURY: RACE IS based medicine is the estimated glomerular filtration
DEVELOPED AS A SOCIAL CONSTRUCT rate Black race coefficient, which is associated with an
Before the 17th century, the term race, “identif[ied] estimated 1.9-year median delay in Black individuals
groups of people with a kinship or group connec- meeting the kidney transplantation wait-list thresh-
tion.”9 The contemporary concept of race, “identif old.21 More examples that put non-White patients at

Table 1. Selected Books and Articles

Topic Title Author(s)

Anti‐racism How to Be an Antiracist Ibram X. Kendi

History of “Race, Medicine, and Health Care in the United States: A Historical Survey” W. Michael Byrd and Linda A.
medicine Clayton
History of Medical Bondage: Race, Gender, and the Origins of American Gynecology Deirdre Cooper Owens
medicine
History of Medical Apartheid: The Dark History of Medical Experimentation on Black Harriet A. Washington
medicine Americans From Colonial Times to the Present
Intersectionality “Double Jeopardy: To Be Black and Female” Frances M. Beal
Intersectionality Demarginalizing the Intersection of race and Sex: A Black Feminist Critique of Kimberlé Crenshaw
Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics
Intersectionality “The Weathering Hypothesis and the Health of African-American Women and Arline T. Geronimus
Infants: Evidence and Speculations”
Systems of “The Enlightenment’s Dark Side” Jamelle Bouie
oppression
Systems of “Health Equity Among Black Women in the United States” Juanita J. Chinn, Iman K. Martin,
oppression and Nicole Redmond
Systems of “Systemic Racism Persists in OB/GYN Care” Angie DeRosa
oppression
Systems of Race: The History of an Idea in the West Ivan Hannaford
oppression
Systems of Caste: The Origins of Our Discontents Isabel Wilkerson
oppression

780 Nnoli Historical Primer on Obstetrics and Gynecology Health Inequities OBSTETRICS & GYNECOLOGY
a disadvantage include the Heart Failure Risk Score, Use of ethnocentric bias by physicians gave birth
Kidney Donor Risk Index, Breast Cancer Risk Assess- to scientific racism, a pseudoscience using unflattering
ment Tool, Fracture Risk Assessment Tool, and pul- beliefs about the bodies and minds of African
monary function tests.16 These modern-day examples descendants that were published as research findings
demonstrate how using race as a biological explana- and scientific theories. One of the most recognizable
tion in medical research creates racial inequities that false beliefs is that Black individuals have higher pain
negatively affect the health care of patients who are thresholds. Justified by this false myth, James Marion
not White in America. Sims performed surgical experiments to correct vag-
inal fistulas without the use of anesthesia on enslaved
1526 AND 1636: FIRST DOCUMENTATION OF women who did not have the power to consent or
AFRICAN AND NATIVE AMERICAN decline his surgeries.46 Unfortunately, these beliefs
ENSLAVEMENT IN THE AMERICAS continue to be perpetuated. In 2015, a textbook titled
By the 1880s, up to 5.5 million Native Americans and Nursing: A Concept-Based Approach to Learning stated
12.5 million African people were enslaved in the that, “Blacks often report higher pain intensity than
Americas.22 The transportation of enslaved African other cultures.[and] believe suffering and pain are
people to the Americas was first recorded in 1526.23 inevitable.” The same text stated that Native Ameri-
Slavery practiced in the original 13 British colonies cans, “usually tolerate a high level of pain without
and subsequent United States was known as chattel requesting pain medication.[and] may pick a sacred
slavery.24 Chattel slavery considered enslaved indi- number when asked to rate pain on a numerical pain
viduals, “personal property of their owners for life, a scale.”47 This information has since been removed.
source of labor or a commodity that could be willed, Studies show that Black Americans continue to be
traded or sold like livestock or furniture.”25 Physicians undertreated for pain compared with White patients
at the time were key participants in the economic and that half of medical students and residents held
system of slavery. Harriet Washington’s Medical Apart- one or more false belief about biological differences
heid: The Dark History of Medical Experimentation on between Black and White patients.48,49
Black Americans From Colonial Times to the Present
reviews how American physicians were, “dependent 1662: PARTUS SEQUITUR VENTREM AND THE
upon slavery, both for economic security and for the INTERSECTION BETWEEN RACE AND SEX
enslaved “clinical material” that fed the American Partus sequitur ventrem, a 1662 legal doctrine estab-
medical research and medical training that bolstered lished by colonial Virginia and adopted by other
physicians’ professional advancement.”26 An example English colonies of early America, codified racial slav-
of this was James Marion Sims, who honed his surgi- ery as hereditary.50 This law defined that children of
cal techniques and quickly advanced his career by enslaved mothers were born into chattel slavery.50 By
experimenting on enslaved women in the 1860, enslaved individuals were, “the largest single
South.25,27–29 Physicians continued to benefit from financial assets in the entire US economy.”39 Enslaved
the unethical use of Black individuals in American individuals were subjected to rape for sexual pleasure
medical research. The U.S. Public Health Service’s and economic benefit. People who owned slaves cre-
Tuskegee Study, from 1932 to 1972, included Black ated the “Jezebel” stereotype of Black women as,
men with syphilis who were not informed of their “highly sexualized and valued purely for her sexual-
infections and never offered treatment.30 In 1951, ity”51 to claim that Black women desired sexual rela-
while she was undergoing treatment at The Johns tions with White men and thus did not need to be
Hopkins Hospital, samples of Henrietta Lacks’ cervi- raped.52 In reality, many enslaved individuals
cal cancer cells were taken without her consent. This endured rape to avoid being sold, beaten, or having
immortal cell line, now referred to as HeLa cells, con- her partner or children sold.52
tinue to be produced for profit and were used in the In 2016, Rosenthal and Lobel8 studied stereo-
development of in vitro fertilization, human papillo- types in the United States related to the motherhood
mavirus and polio vaccines, and drugs for treating and sexuality of Black women. The study found that,
Parkinson disease, hemophilia, leukemia, and human compared with White women, Black women were
immunodeficiency virus (HIV).31 The historical believed to, “hav[e] had sex with more people,” to
trauma, ethnocide, and genocide within these commu- be “less likely to use birth control,” “more likely to
nities have contributed to the current mistrust of have children,” to “receive some form of public assis-
health care professionals and health care systems tance,” to “have less education,” and to “earn less
among Black and Native American communities.32–45 income.” Participants perceived pregnant Black

VOL. 142, NO. 4, OCTOBER 2023 Nnoli Historical Primer on Obstetrics and Gynecology Health Inequities 781
individuals as, “less likely to have the father of the print to create their own Law for the Prevention of
child involved” and “more likely to need public assis- Offspring With Hereditary Diseases, which led to the
tance” compared with White pregnant individuals.8 forced sterilization of about 400,000 mostly Jewish
These stereotypes continue to be perpetuated in the children and adults.61 The 1927 U.S. Supreme Court
American media.53 case Buck v Bell supported a Virginia law legalizing
Concepts to describe the negative effects of the, “sterilization of inmates of institutions supported
stereotypes include stereotype internalization, stereo- by the state,” setting a legal precedent that other states
type threat, and allostatic load. Stereotype internali- soon followed.63 In his opinion, Justice Oliver Wen-
zation may occur when one becomes aware of society dell Holmes Jr stated that, “three generations of imbe-
stereotypes related to their group identity, starts to ciles are enough.”64 Although Virginia repealed its
believe that they are true, and, ultimately, incorpo- sterilization law in 1974, the Supreme Court decision
rates these stereotypes into their own self-concept.8 has not been overturned.64
Stereotype threat describes when a person is anxious California’s 1909 Asexualization Act authorized
about possibly confirming a stereotype about their the involuntary sterilization of 20,000 men and
group.8 A 2013 study by Jones et al54 showed that women who were disproportionally Black and Latinx
health-related stereotypes about Black Americans individuals. A 1976 civil rights class action lawsuit,
were associated with delays in seeking medical care.54 Madrigal v Quilligan, filed by 10 Mexican Americans
Being the subject of such stereotypes can result in against the Los Angeles County University of South-
Black individuals experiencing greater distress ern California Medical Center, finally banned invol-
throughout life, including during pregnancy.55 A term untary sterilization in 1979.65,66
that encapsulates this experience is allostatic load, Mississippi passed a sterilization law in 1928
which refers to the, “cost of chronic exposure to fluc- under which 683 involuntary sterilizations were
tuating or heightened neural and neuroendocrine performed until 1963. The civil rights leader and
responses resulting from repeated or chronic environ- voting and women’s right activist Fannie Lou Hamer
mental challenges.”56 Allostatic load is the cumulative was a victim of this law. She received an involuntary
burden of chronic stress and life events. It has been hysterectomy after consenting to a myomectomy.
associated with adverse pregnancy outcomes such as Hamer became a powerful leader and symbol of the
preterm birth, stillbirth, newborns small for gesta- southern civil rights movement by sharing her expe-
tional age, and hypertensive disorders of preg- rience of having a “Mississippi appendectomy.”26
nancy.56–58 Allostatic load in relation to stereotype This historical legacy of injustice has shaped contem-
threat, along with other forms of systemic racism, porary perceptions of health care. A 2021 qualitative
may explain some of the reproductive and pregnancy study showed that Black women seeking surgical
disparities in Black individuals. treatment for leiomyomas expressed “medical mis-
trust or skepticism” and questioned “whether Black
1900s: AMERICAN EUGENICS MOVEMENT women were valued less in clinical settings” and
AND FORCED STERILIZATION “whether clinicians targeted Black women for hyster-
Historically rooted stereotypes and myths about Black ectom[ies] compared with non-Black women.”67
women have shaped U.S. public policies governing When hysterectomies are performed, White women
reproduction and family life. Examples of these are more likely to undergo laparoscopic procedures,
policies include anti‐miscegenation laws, birth control whereas Black women are more likely to undergo
campaigns during the eugenics movement, and abdominal procedures, even for the same
government-funded sterilizations.59 During the eugen- indication.68
ics movement, which began in the late 19th century, Jane Lawrence’s69 article “The Indian Health Ser-
Black individuals were labeled as, “sexually indiscrim- vices and Sterilization of Native American Women”
inate” and “bad mothers who would give birth to found that the Indian Health Services sterilized nearly
defective offspring.”60 To maintain “racial hygiene,” 25% of Indigenous individuals during the 1960s and
prominent eugenicists touted false theories involving 1970s. A 1970s investigation of 4 of the 12 Indian
the scientific inferiority of Black, Latinx, and indige- Health Services programs located in Aberdeen, Albu-
nous peoples, as well as individuals with disabilities querque, Oklahoma City, and Phoenix found the
and low income.61–65 majority of physicians were, “White, Euro-American
The world’s first sterilization law was passed by males who believed that they were helping society by
Indiana in 1907 and eventually adopted in 32 states. limiting the number of births in low-income, minority
Nazi Germany used U.S. sterilization laws as a blue- families.”69 During this investigation, the affected

782 Nnoli Historical Primer on Obstetrics and Gynecology Health Inequities OBSTETRICS & GYNECOLOGY
Native American individuals were overlooked by diversity, acknowledge systemic racism, eliminate
investigators, who, “believed that such an effort would bias, and create an inclusive environment.
not have been productive,”69 thus excluding the most The Association of Professors of Gynecology and
valuable perspectives of these inhumane policies.69,70 Obstetrics (APGO) created a Diversity, Equity, and
Government-imposed incentivization of steriliza- Inclusion Guidelines Task Force in 2020 to move
tion continues to be used by the criminal legal system, “towards a just, antiracist workplace and learning
with inmates obtaining sterilization in exchange for a environment.”80 Members of this task force included
reduced sentence. In the 1990s, the U.S. Food and medical education leaders of ethnically and racially
Drug Administration approved Norplant as an easy- diverse backgrounds. The Guidelines are divided into
to-use, safe, and effective contraceptive implant that four domains: Learning Environment (inclusive lan-
led to similar reproductive coercion within the legal guage and anti‐racism education); Grading and
system.71 Shortly after Norplant received U.S. Food Assessment (faculty and assessor bias training, stan-
and Drug Administration approval, the Philadelphia dardized evaluation and grading rubrics); Pathway
Inquirer published an editorial on December 12, programs, recruitment, retention and promotion in
1990, titled “Poverty and Norplant: Can Contracep- the health professions (enhance opportunities and
tion Reduce the Underclass?”72 At the same time, provide mentorship for students historically excluded
state welfare systems used the racist mythology of from medicine); Metrics (track outcomes of diversity
Black women as “hypersexual” and “welfare queens” and inclusion efforts, provide routes for reporting bias
to justify Norplant marketing practices toward low- or discrimination, and measure recruitment and reten-
income Black individuals, Black adolescents, and tion). This task force is currently working on guide-
Black young adults by incorporating Norplant adver- lines to address additional identities, including sexual
tisements in state welfare systems and high school orientation, gender identity, gender expression, and
programs.59,72 Currently, 31 states and Washington, sex characteristics. Guidelines and research are
DC, have laws allowing court-ordered sterilization of needed to address additional systems of oppression
those who are disabled, with 17 of these states allow- (eg, disability, religion).
ing forced sterilization of disabled children.73,74 In Inclusion of anti‐racism training as an Accredita-
2020, allegations of forced hysterectomies and other tion Council for Graduate Medical Education
unwarranted gynecologic procedures at the Irwin (ACGME) common program requirement is an
County Detention Center in Georgia resulted in an actionable step to encourage learning environments
18-month Senate investigation of the now-closed facil- to operationalize anti-racism.81 As part of an anti-
ity. The investigation found, “excess, invasive, and racism core competency, the history of U.S. slavery
often unnecessary gynecological surgeries and proce- and its effect on medicine would highlight the, “false
dures, with repeated failures to obtain informed med- premise of racial groups as distinct biological popula-
ical consent.”75 [Link] the role of racism as a preventable etiology
of racial health disparities.”80,81 Anti-racism training
based in abolition medicine, critical race theory, and
CONCLUSION decolonization frameworks, rather than, “sanitized,
The systems of oppression that resulted from U.S. apologetic frameworks centering White [individuals’]
slavery are reflected in U.S. health disparities and comfort and passivity, such as racial disparities and
inequities. This is evidenced by the disproportionate cultural [Link] the invisibility of
rates of U.S. maternal mortality among Black indi- Whiteness visible to highlight its role in upholding
viduals and American Indian–Alaska Native individ- medical racism and preventing change.”82 Addressing
uals.76–79 A more equitable health care system can be the cause of racial disparities is likely more effective
achieved by acknowledging the legacy of slavery and than just focusing on the outcomes of racism.
U.S. federal slave laws in creating persistent systems The U.S. health care system is a reflection of the
of oppression and inequality in American society, society and government it operates within. Moving
American government, and its health care system. beyond rote declarations of solidarity allows us to
Without this understanding, health care professionals understand and integrate anti-racism within ourselves,
may use false assumptions that are influenced by ste- thereby positively affecting health care systems and
reotypes and biases in an attempt to explain health beyond.81 We must commit to being anti-racist by
outcomes. first acknowledging that all of us, “exhibit unconscious
Health care systems should use practices biases as a byproduct of socialization.[and some]
and standards that are evidenced-based to increase harbor overtly racist attitudes.”81 We can then

VOL. 142, NO. 4, OCTOBER 2023 Nnoli Historical Primer on Obstetrics and Gynecology Health Inequities 783
normalize the action of calling out racism within clin- of vaginal birth after cesarean delivery. Obstet Gynecol 2007;
109:806–12. doi: 10.1097/[Link].0000259312.36053.02
ical and nonclinical spaces.81 The work ahead is chal-
lenging. It requires us to understand this appalling 16. Vyas DA, Eisenstein LG, Jones DS. Hidden in plain sight: re-
considering the use of race correction in clinical algorithms. N
history because those who do not know their history Engl J Med 2020;383:874–82. doi: 10.1056/NEJMms2004740
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