Shakima Tozay was 37 years old and six months pregnant when a nurse, checking the fetal heart rate of the baby she was carrying, referred to him as “a thug.”
Tozay, a social worker, was paralyzed. She had just been hospitalized at Providence Regional Medical Center in Everett, Washington, with preeclampsia, a potentially fatal complication of pregnancy, and she is black.
“A ‘bandit’?” she said. “Why would you call him that?” The fetus was 40.6 centimeters long and weighed little more than a box of chocolates.
A doctor who entered the room downplayed the comment, saying the nurse was just joking, but this only hurt Tozay even more. She was already distressed: she and her husband had previously lost a twin pregnancy, and now she was worried that this baby was also at risk. The hospital later apologized for the nurse’s behavior, but the damage was already done.
Black women, who die from pregnancy-related complications at two to three times the rate of white women, say comments like these, often made when they are at their most vulnerable, reflect a widespread bias in the medical system. They report that medical staff do not listen to them when they complain of symptoms and dismiss or minimize their concerns. Studies validate their experiences: Analyzes of recorded conversations between doctors and patients have found that doctors dominate the conversation more often with black patients and don’t ask as many questions as they do with white patients. In medical notes, doctors are more likely to express skepticism regarding symptoms reported by black patients.
Looming over these experiences is the harsh reality that Black women have worse pregnancy outcomes, lose more babies in the first year of life, and have higher rates of premature birth and stillbirth compared to white women. Stark racial disparities in health outcomes persist between white women and even wealthier Black women, and between Black women and white women who face the same complications.
These discoveries forced the medical establishment to recognize and confront its biases. Many health systems have made anti-bias training mandatory for faculty. Some hospital committees that review cases with poor outcomes to identify causes are now considering whether racial bias played a role.
Experts who study bias in medical care say that the vast majority of people in the health professions have good intentions, but that even professionals who reject explicit racism have internalized cultural stereotypes, and that this unconscious or implicit bias can influence medical care. and the way they relate to patients.
“They’ll say, ‘Hey, I’m not prejudiced,’ and knowingly they aren’t,” says Cristina Gonzalez, professor of medicine and associate director of the Institute for Excellence in Health Equity at NYU Langone Health. “But the unconscious runs much of the show during the day.”
The brain is wired to make decisions quickly, said Sarah Wilson, an assistant professor at Duke University. It uses cognitive shortcuts that allow bias to creep in, especially when a person is uncertain, tired or stressed — common circumstances in a busy practice or hospital, where providers often treat patients they don’t know.
“If it’s a very complicated situation and you have to make a decision immediately,” Wilson said, “then it’s very natural to fall back on those automatic assumptions.”
‘They sent us away’
Tozay was sent home from the hospital that night in 2017 for bed rest. Preeclampsia, a serious condition that causes extremely high blood pressure, can lead to premature birth, stillbirth, organ damage and, ultimately, eclampsia — a sudden seizure that can be fatal for both mother and baby.
Tozay and her husband, Glen Guss, kept an eye on her blood pressure, measuring it frequently with a device. A few days later, she began to rise precipitously. During pregnancy, high blood pressure begins when the top number, which is systolic blood pressure, reaches 140 or more, or the bottom number, diastolic blood pressure, reaches 90 or more. One of Tozay’s systolic pressure readings was in the 190s, Guss said. Deeply concerned, he took her back to the hospital.
The triage nurse seemed concerned and told the couple that she would take Tozay’s blood pressure again as soon as she calmed down. Some tests were done, and while Tozay waited to be seen by a doctor, her blood pressure dropped to 149/81, according to her medical records, still very high.
Then, Tozay and her husband said the nurse told them that the attending doctor had said Tozay could go home. Guss said, in retrospect, the hospital did not give enough weight to the factors that put his wife at high risk: her relatively old age at childbirth, previous miscarriage, uterine fibroids, low amniotic fluid, early contractions in pregnancy and diagnosis of pre- eclampsia. He and Tozay said they never had the chance to tell a doctor that she felt something was very wrong, was dizzy and had a “surreal” feeling.
A hospital spokeswoman, Melissa Tizon, said only a doctor could have ordered the tests Tozay had, but she could not confirm from hospital records whether a doctor actually examined her. She said a doctor was “involved” in Tozay’s care, but added: “We cannot say whether the doctor was face to face with the patient.” Tizon said a hospital review of the interaction concluded it “met appropriate standards of care.” (Tozay gave written consent for hospital staff to discuss her care.)
Not having a doctor examine a woman who entered the screening room at Tozay’s stage of pregnancy would be very unusual, says Tanya Sorensen, an obstetrician specializing in high-risk pregnancies who oversees women’s health care in a region of the Providence health system. which includes the hospital where Tozay was treated.
“I wish I had said, ‘No, I’m not going home,'” Tozay said recently. “But I didn’t know what was going on. My husband didn’t know. We were trusting that they knew.” Guss said: “There were so many red flags saying they should have taken it down immediately. But they sent us away.”
The next morning, the fetus was not moving.
Stereotypes and Skepticism
In interviews, many black women complained of being stereotyped by administrative staff, nurses and doctors, and of being repeatedly asked about their marital status and health insurance — even when they wore a wedding ring, had a hyphenated last name or had private insurance.
“I was always asked, ‘Where’s your baby’s daddy?'” said Ruhamah Dunmeyer Grooms, 35, a business analyst and mother who lives outside Charleston, South Carolina. “I don’t have a baby daddy. I have one husband.”
Black women are more likely to be tested for illicit drugs during labor and delivery than white women, regardless of their substance use history, and even though they were less likely than white women to test positive, a study found recent.
In a study of patient records, researchers found that doctors show disbelief in the records of black patients, appearing to question the credibility of their complaints by placing quotation marks around certain words—for example, writing that the patient “had a ‘reaction’.” ‘to medication”—or describing a complaint with words like “allegations” or “insists.”
Not taking patients seriously and believing their stories can have fatal consequences.