Shakima Tozay was 37 years old and six months pregnant when a nurse, checking the fetal heart rate of the baby boy she was carrying, referred to him as “a hoodlum.” Ms. Tozay, a social worker, froze. She had just been hospitalized at Providence Regional Medical Center in Everett, Wash., with pre-eclampsia, a life-threatening complication of pregnancy, and she is Black.
“A ‘hoodlum’?” she said. “Why would you call him that?”
The fetus was 14 inches long and weighed little more than a box of chocolates.
A doctor who came into the room downplayed the comment, saying the nurse was just kidding, but that only hurt Ms. Tozay more. She was already distressed: She and her husband lost an earlier twin pregnancy, and now she worried this baby was at risk, too. The hospital later apologized for the nurse’s behavior, but the damage was done.
Black women, who die of pregnancy-related complications at two to three times the rate of white women, say that remarks like these, often made when they are most vulnerable, reflect pervasive bias in the medical system. They report that medical staff don’t listen to them when they complain of symptoms, and dismiss or downplay their concerns. Studies validate their experiences: Analyses of taped conversations between physicians and patients have found that doctors dominate the conversation more with Black patients and don’t ask as many questions as they do of white patients. In medical notes, doctors are more likely to express skepticism about the symptoms Black patients report.
Hovering over these experiences is the stark reality that Black women have worse pregnancy outcomes, lose more infants in the first year of life and have higher rates of preterm birth and stillbirth, when compared with white women. Glaring racial disparities in health outcomes persist between white women and even the wealthiest Black women, and between Black women and white women who experience the same complications.
These findings have forced the medical establishment to acknowledge and confront its biases. Many health systems have mandated anti-bias training for faculty. Some hospital committees that review cases with poor outcomes in order to identify the causes now consider whether racial bias played a role.
Experts who study bias in medical care say that a vast majority of people in the healing professions have good intentions, but that even providers who reject overt racism have internalized cultural stereotypes, and that this unconscious or implicit bias can influence medical care and bedside manner.
“They will say, ‘Hey, I’m not biased,’ and consciously they are not,” said Dr. Cristina M. Gonzalez, a professor of medicine and an associate director at the Institute for Excellence in Health Equity at NYU Langone Health. “But the unconscious runs a lot of the show during the day.”
The brain is wired to make decisions quickly, said Sarah M. Wilson, an assistant professor at Duke University. It uses cognitive shortcuts that let bias seep in, especially when a person is uncertain, tired or stressed — common circumstances in a busy practice or hospital, where providers often treat patients they do not know.
“If it’s a very complicated situation and you have to make a decision at a moment’s notice,” Dr. Wilson said, “then it is very natural to fall back on these automatic assumptions.”
“They sent us away”
Ms. Tozay was sent home from the hospital that evening in 2017 on bed rest. Pre-eclampsia, a serious condition that causes extremely high blood pressure, can lead to preterm birth, stillbirth, organ damage and ultimately eclampsia — a sudden seizure that can be deadly for mother and baby.
Ms. Tozay and her husband, Glen Guss, kept a close eye on her blood pressure, measuring it often with a cuff. A few days later, it started climbing precipitously. During pregnancy, hypertension starts 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 Ms. Tozay’s systolic pressure readings was in the 190s, Mr. Guss said. Deeply worried, he drove her back to the hospital.
The intake nurse looked concerned and told the couple she would measure Ms. Tozay’s blood pressure again once she had calmed down. Some tests were done, and while Ms. Tozay waited to be seen by a doctor, her pressure declined to 149/81, according to her medical records, still too high.
Then, Ms. Tozay and her husband said, the nurse told them that the attending physician had said Ms. Tozay could go home.
Mr. Guss said in retrospect that the hospital did not give enough weight to factors that put his wife at high risk: her relatively advanced age for childbirth, previous miscarriage, uterine fibroids, low amniotic fluid, contractions early in the pregnancy and the pre-eclampsia diagnosis. He and Ms. Tozay said they never got the chance to tell a doctor that she felt something was very wrong, had been lightheaded and had “a surreal kind of feeling.”
A spokeswoman for the hospital, Melissa Tizon, said only a doctor could have ordered the tests Ms. Tozay was given, but she could not confirm from hospital records whether a physician actually examined her. She said that a physician had been “engaged” in Ms. Tozay’s care, but added, “We can’t tell if the physician was face to face with the patient.” Ms. Tizon said a hospital review of the interaction concluded that it “met the appropriate standards of care.” (Ms. Tozay gave written consent for hospital officials to discuss her care.)
Not having a physician examine a woman who came into the triage room at Ms. Tozay’s stage of pregnancy would be very unusual, said Dr. Tanya K. Sorensen, an obstetrician specializing in high-risk pregnancies who oversees women’s health care for a region of the Providence health system that includes the hospital where Ms. Tozay was treated.
“I wish that I had said, ‘No, I’m not going home,’” Ms. Tozay said recently. “But I didn’t know what was going on. My husband didn’t know. We were trusting that they knew.”
“There were so many red flags saying they should just take him out right away,” Mr. Guss said. “But they sent us away.”
The next morning, the fetus was not moving.
Stereotypes and skepticism
To better understand how bias plays out, I interviewed dozens of Black women who described disturbing experiences with health care providers during their pregnancies. Their accounts were corroborated whenever possible by medical records, emails with providers and other documentation, as well as interviews with family members and hospital officials.
In Ms. Tozay’s case, the hospital spokeswoman, Ms. Tizon, confirmed that Ms. Tozay filed a complaint with the hospital on Nov. 6 about the nurse’s hoodlum remark on Nov. 3. The manager of the hospital’s childbirth center, Lisa Von Herbulis, met with the nurse to discuss her lack of sensitivity and wrote a letter of apology to Ms. Tozay, dated Nov. 16, a copy of which Ms. Tozay shared with The New York Times.
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 insurance — even when they wore a wedding band, had a hyphenated last name or had private insurance.
“I was always being asked, ‘Where’s your baby daddy?’” said Ruhamah Dunmeyer Grooms, 35, a business analyst and mother who lives outside Charleston, S.C. “I don’t have a baby daddy. I have a husband.”
Black women are more likely to be tested for illicit drugs during labor and delivery than white women, regardless of their history of substance use, and even though they were less likely than white women to test positive, a recent study found.
Other studies indicate that physicians may express less empathy for Black patients, compared with white patients, and their notes reflect a belief that Black patients are less likely to follow medical advice.
They are more likely to describe Black patients as uncooperative or “noncompliant,” and they may prescribe less aggressive treatment because they don’t think Black patients will adhere to it, experts say.
In one study of patient records, researchers found that doctors signal 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 the medication” — or by describing a complaint with words like “claims” or “insists.”
Failure to take…