SART Fertility Experts - Racial Disparities in REI

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Welcome to this episode of SART Fertility Experts, the podcast for people trying to build a family. I'm your host, Dr. Kelly Lynch, and my guest today is Dr. Gloria Richard-Davis of the University of Arkansas for Medical Sciences and she is Division Director of Reproductive and Endocrinology and Infertility. Dr. Richard-Davis is a tenured professor of obstetrics and gynecology and has served in numerous leadership roles in academic medicine and, recently, the University of Arkansas for Medical Sciences Division for Diversity, Equity, and Inclusion as its Executive Director.

Today, I've asked Dr. Richard-Davis to discuss the issue of racial disparities in reproductive endocrinology and infertility, a topic about which Dr. Davis has published extensively. Welcome, Dr. Richard-Davis. Thanks so much, Dr. Lynch, for having me.

I'd like to begin with a question for you. We know there is a long history of racial injustice in medicine in the U.S. Can you share some instances of historic injustice in reproductive medicine with us? Certainly. You know, probably the best known in our field is when we talk about Dr. Marion Sims, which dates back to the work that he did on the now known names of the three slave women, Lucy, Betsy, and Arka.

I was privileged to visit that museum recently and it's just very, very touching to see that someone has taken this as their personal project because it's a private citizen who bought the home and has erected this museum. It's really phenomenal to be able to see that. That's one thing.

But, you know, I mean, even as we come forward to contemporary times, and when I say that, I mean like the 70s, right, where Black women have been historically sterilized. Even the courts, right, have ordered sterilization procedures on women without their consent. The number of women who have had procedures done on them, and they don't know what it is, is significant.

In our gynecological world, what we know about the data related to hysterectomies is that Black women, particularly in the southeastern region, there are more hysterectomies done on Black women than any other race. And so, you know, that just continues to sort of underscore the foundation on which our educational healthcare system is based on. I absolutely agree with you.

And it also seems like, as you have also pointed out, there's a very big emphasis on offering contraception, but not always the converse, offering fertility care. And it seems like it results in unequal treatment for women of color. What do you think is the greatest barrier to accessing infertility testing and treatment for women of color? We have recently done a project at Morehouse School of Medicine in Ferry, where we've interviewed 77 Black women who are in fertility treatment and really asked that question of them.

And what I want to say from the beginning is the average income of those women was $110,000. So, you know, unlike most of our perception is that finances is a barrier. Finances were not a barrier.

But what they talk about is their experience, you know, from the minute that they step in the doors of fertility practices, they don't see themselves, they don't feel heard, they don't feel welcome. And so I think that adds to the delay that we see with women coming in for care. It also adds to the number of women that we see walking away from treatment before they are successful in achieving a pregnancy, right? And I mean, there clearly are other reasons just when we talk about the historical marginalization of women of color, that certainly adds to the delay.

Embedded in some of that are also religious beliefs, which sometimes, again, begin to make people think that if it's meant to be for you, it will happen. So, you know, all of these undercurrents or undertones lead to Black women entering care later, at least a year. And we know that age is such a critical factor in success, right? Absolutely.

Makes a huge difference. And if they walk away and don't come back for another three or four years, that's even more of an issue. What are some of the reasons that Black and Brown women might leave care sooner or not continue with care? What do you think is going on? I think some of it is cultural malalignment.

It's what I'm going to call it, right? That is the way that we approach conversations with patients and make sure that they understand; I oftentimes say to my staff, right, what we talk about is very complex. The instructions we give to patients are very complex. And even physicians who are in fertility care that are not in this area don't understand it.

Absolutely. They struggle with the instructions, the medications, and the multiple. Exactly.

But they're confident enough to ask the questions, right? Whereas if you have someone who is not feeling like they should be there or that, you know, you're going to think that they are less than because they don't know or they don't understand, then that adds to it. So we have to work hard in making sure that these women feel welcome and that they feel like they belong and help identify and come to where they are at, is what you're saying. Absolutely.

Absolutely. Meet them where they are. I also want to circle back to something you said because, believe it or not, it came out specifically that way in one of our interviews about the fact that Black women are consulted about contraception all day long because of the perception that we're hyperfertile, right? But no one really talks to them about their plan for pregnancy, their procreativity.

And that was said repeatedly. If they had been educated and they knew earlier, it would have been very helpful. And they feel like they have to do a lot more research before even coming in.

And they talk about arming themselves before coming to the visit so that they, again, at least approach it by sounding intelligent, right? Right. The position to the office staff. More delays.

More delays. What about infertility mandates? There are some states that have infertility mandates. Do they help improve access? They do help, but it certainly doesn't equalize the playing field.

We've looked at that data repeatedly, and it pretty much all says the same. It does help. There's no doubt.

But we're still dealing with the barriers that exist. The access. We know that we don't have a lot of fertility clinics across the country.

So there is still that delay, even in being referred for care. So if they are really proactive and advocating for themselves, there may still be challenges with access, as well as when we look at what we require of women to be in active treatment. It's a lot.

It is. If they have a regular job, it puts them at risk. Absolutely.

It's really hard to make all of these appointments, get time off, and have a flexible schedule. And it's also an invasion of privacy to have to fill out those FMLA forms, get time off, and tell your employer what you're doing. It's difficult for everyone.

Exactly. And we know there is, particularly in Black communities, there's more of a stigma about infertility. And so when you say acknowledging it, whether it's to your employer, they worry about their employment being at risk.

If they're missing too much work, if they know they're planning a pregnancy, all of those things. I just want to go back to one question. Do you think Black and Brown women are treated differently in our healthcare system? And what can we do about it? I absolutely think we're treated differently.

And I don't think that it is intentional on the part of the providers. I think it's the implicit biases that are embedded in our society, that are embedded in our healthcare system that we all trained in. I have to check myself as a Black woman, because I've been trained in the same system as you, right? Right.

And so the same biases and misperceptions have been embedded in my head as well. So I have to be very, very intentional about recognizing some of the challenges that exist within our system that really put up and create more barriers than access. And so I think all of us if we could just, the old adage, walk a mile in someone else's shoe, right? If we could just stop and think a little bit about what that person's life is like.

There was a documentary called Toxic, and it really follows a Black attorney through her everyday life. And she was early pregnant, risking miscarriage. But what they showed is the daily kind of assaults and microaggressions and macroaggressions that occur.

And all of those things build on itself. What we know is that chronic tonic stress weathers, right? Right. And we internalize it and it wears on us.

Absolutely. Absolutely. So there are lots of reasons why we want to be sensitive to that as healthcare providers and do our part in trying to dismantle some of it, try to mitigate against some of it.

Why do you think Black and Brown women might avoid the healthcare system altogether? What are the things that are keeping them away from us or preventing them from getting to care? We know economic barriers are a significant one, but what are the other barriers? I think when we look at the history of Black communities and the healthcare system, we talked about some of that earlier. I think that's still an issue. We saw that with the COVID vaccine, the hesitancy.

I will tell you that I did focus groups in Black and Brown communities. And there is an element of mistrust that is still there, right? Questioning even me as a Black physician. Am I really telling them the truth? Because they see me the same as they see you many times.

Right. So our legacy in medicine is one that has not earned the trust of women. When Black and Brown women achieve pregnancy successfully, we know that they are at increased risk for poor maternal and neonatal outcomes.

Why do you think that is? The CDC has an entire campaign built on two words, hear her. Because oftentimes patients know something's wrong. They know something's going on.

They're trying to tell us that, but they're not heard. And so that certainly adds to the delay of treatment and sometimes the missing of diagnosis. The other thing that I think is we have more comorbidities as a group.

Okay. Our rates of obesity are higher, and our rates of hypertension and diabetes are due to everything from the stressors that we talked about in everyday life. I'm doing a, or I just submitted a proposal recently on looking at food insecurity and the impact that it has on increasing incidences of chronic diseases, right? Like obesity and diabetes.

So all of those things add to the morbidity that women bring to the pregnancy. And we know that we do a poor job of preconception counseling. I can't, you know, for everybody who's out there seeing women pre-pregnancy, we have the opportunity to address those things, to make sure that their control, their hypertension is controlled, their diabetes is controlled.

Talk about weight management. They're not conversations, but you have to have them. Right.

It's an opportunity to intervene and maybe help someone have a good outcome. So for example, avoid processed foods and excess salts. So I hear you and also try to avoid or try to keep our blood sugars in the normal range.

So lots of things that we can do pre-pregnancy to help improve our outcomes. Yes. To be proactive, increase our activities.

You also mentioned in some of your writing that Black and Brown women may also experience more severe menopause symptoms and have a longer duration of symptoms. Yes. It's interesting because, in the menopause arena, most of us were kind of taught vasomotor symptoms, hot flushes, and night sweats, which are fairly short-lived.

But the study of women across the nation, the SWAN study, which longitudinally looked at women's symptoms from perimenopause to menopause, postmenopause, really contributed a lot of information to our literature, which documented very well that Black and Brown women experienced menopausal symptoms for a longer period of time. They're also more severe. If you look at the average years of vasomotor symptoms for Caucasian women, it's about four and a half, five years.

For Hispanic women, it's about eight years, eight plus years, eight to nine. And then for Black women, it's 10 plus. There is a marked difference in the length of time that these women are experiencing symptoms and the fact that they're more severe.

So as I listen to you say this, our listeners are trying to get pregnant, they're experiencing infertility and they're trying to learn as much as they can about infertility treatment, but it's also important to understand at some point, all of us women are going to go through menopause. And so it's just important to hear that there are effective treatments for menopause and that they're available to everyone. Make sure that you reach out to your reproductive endocrinologist or obstetrician/gynecologist for help with your symptoms. You don't have to suffer such prolonged symptoms.

Absolutely. Absolutely. Because it does affect the quality of life.

And there is some data to suggest that it also affects longevity to go untreated. Because think about one of the major symptoms when we talk about hot flushes and night sweats is the disruption of our sleep. We don't get into REM sleep.

We don't have quality sleep that contributes to chronic tonic cortisol levels and stress hormones, which then, of course, increases cardiovascular disease, et cetera. So lots of reasons not to go untreated. Makes sense.

I'm so glad you highlighted that important issue for our listeners. So as we hear about all of the problems that are going on in our specialty, how can we improve reproductive medicine care for women of color? Can you highlight some of the initiatives that you're working on? Absolutely. So, in my principal role at the University of Arkansas as Executive Director for the Division for Diversity, Equity, and Inclusion, our primary goal is really diversifying the workforce.

And the realization is we probably will never really reach population equity, but by having a diverse workforce, you bring those different perspectives into our care realm. And it does help to improve treatment for everyone. There's data that shows that just having a diverse team, the outcomes are better.

So that's one of the things that I think is critical. And so we are in ASRM, we have the working committee on diversity, equity, and inclusion that I chair. And about two years ago, Serono had an RFA that I responded to, to create a virtual mentoring platform to raise awareness for our black and brown OBGYN residents who don't know anything about reproductive endocrinology.

Most don't have any exposure until maybe during their senior year of residency. And we know that our fellowships are very competitive. When you look at the fellowship directors survey, research is one of the biggest things that they value in deciding on their selected applicants.

And they don't have time to do that if they're in their junior or senior year. So what we're trying to do is increase awareness, particularly for residents that are in programs not affiliated with REI fellowship programs, and to recruit black, brown, underserved residents in OBGYN and pair them with mentors. So if you have an interest, we would be happy to have you join us on this journey.

We have a platform that individuals sign into, they create profiles, and I'm specifically looking for individuals who are, who have the time to mentor and coach, both from a professional perspective, but also the research aspect, because as I pointed out, that's so critical. We've had even within the two years that we've been doing this, the first we have identified what we call the DEI fellow, right? The Serono DEI fellow. And our first fellow was at Morehouse School of Medicine.

She was a third-year OBGYN resident. We paired her, actually, I knew her because of one of my medical school, I'm sorry, one of our medical school students from Arkansas, who's at Morehouse, who introduced her to me early on. So we paired her with Boston IVF, and she did a clinical rotation with them.

She did research with Allen and presented her work at ASRM. And I'm happy to report that she matched with Barbara Wood Johnson. Oh, wonderful.

I think I actually saw her on the interview trail. She, I think we interviewed her in our program as well. I'm really happy to hear that.

That's wonderful. And just to emphasize the importance of this, we want diversity in our specialty because we know our Black and Brown patients want to be taken care of by women like themselves and want to be taken care of by doctors like themselves who understand their lived experience. So this is a really wonderful program because we need to increase diversity in our specialty.

Absolutely. And I think I have to step back and underscore the fact that it's also not just the physician, right? When we have the opportunity to hire office staff, think about it with an equity lens and add some diversity to your office staff as well. Right.

Make sure that our patients feel that they see people they identify with when they come to the office. I think that's a really great suggestion for us. Absolutely.

We're working with Faring on creating some modules that really address a lot of the issues that we're talking about from a cultural humility perspective so that we kind of see it from different lenses, right? These are really great initiatives and I really hope that it makes a difference. It sounds like it already is starting to make a difference, but for our patients and our listeners out there, please know that this is something that we are committed to working on and we want to hear from you how we can help make this experience better for you. Dr. Rashard Davis, thank you for all that you're doing and thank you for taking the time to talk with me today about your work, improving diversity, equity, and inclusion in reproductive medicine.

It's been an absolute pleasure, and clearly, it's something that I'm very passionate about. Thank you. You're welcome.

Thank you. Thank you, everyone. You have just listened to our episode of the SART Fertility Experts Podcast.

Have a good day.