Biological writings from the late 19th century rest on the Darwinian theory that women are inferior to men physically and mentally — men were, after all, subjected to greater selective pressures through war, hunting, and competition for mates, or so the conventional wisdom went.
It’s no surprise that in the year 2023, sex and gender disparities in health care persist. While previous theories about inferiority have long since been debunked, their legacy lives on in modern-day inequity: unmet needs for maternal health, dismissal and undertreatment of women in the clinic, underrepresentation in trials, and lack of funding for diseases that affect more women than men.
Addressing Maternal Mortality
Maternal death has been on the rise in the U.S. since 2018, according to the Centers for Disease Control and Prevention. In 2021, the maternal mortality rate was 32.9 deaths per 100,000 live births, up from 23.8 in 2020 and 20.1 in 2019.
The causes behind this rise are varied, according to Yale Medicine, and range from inequities in health care to women giving birth at older ages to an increase in chronic health conditions.
Additionally, in 2021, the maternal mortality rate for Black women was 69.9 deaths per 100,000 live births, compared with 26.6 for white women — a result of systemic racism, which leads Black mothers to have less access to health care and less financial help.
They also must deal with more severe chronic stress and are often treated unfairly by medical professionals.
The same racial disparities can be seen locally. The rate of pregnancy-related maternal deaths between 2015 and 2019 in Detroit was 43.7 per 100,000 live births for Black women and zero for white women, according to state statistics. Among the pregnancy-related deaths, 52.9 percent were determined to be preventable.
Gov. Gretchen Whitmer has worked to improve those stats — in April 2022, she launched the Healthy Moms, Healthy Babies initiative, expanding postpartum Medicaid coverage from 60 days to 12 months.
In January, as part of the initiative, Michigan became one of the first states to cover doula services. The recently passed 2024 state budget allocated $56.4 million for Healthy Moms, Healthy Babies.
Earlier this year, Whitmer named April 11-17 Black Maternal Health Week in Michigan to acknowledge the prenatal and postpartum experiences of Black mothers in the state.
In 2020, Whitmer also signed an executive directive to charge the state’s Department of Licensing and Regulatory Affairs with developing rules that require implicit bias training for health professionals to address disparities in treatment.
“Black mothers in Michigan deserve to have access to quality affordable maternal and infant health care and a supportive, caring environment that leads to a healthy pregnancy,” Whitmer said in April. “Let’s keep working together to ensure Michiganders — no matter where they live or who they are — can have a healthy pregnancy.”
Overlooked and Underserved
A wealth of research supports the troubling reality that women’s health complaints — in all areas, not just obstetrics — are too often minimized or dismissed by medical professionals.
Women in pain are more likely to receive sedatives than pain medication. They are half as likely as men to receive painkillers after a coronary bypass surgery.
And pain isn’t just undertreated in specialist settings but in triage as well: Men wait an average of 49 minutes before receiving pain medication for acute abdominal pain in the emergency department, while women wait an average of 65 minutes.
Other symptoms that women report are also often brushed aside.
“Heart disease is the No. 1 killer in women, and sometimes the symptoms can be different — but even when women present with the same symptoms, they may not be taken seriously,” says Dr. Dee Fenner, chair of the Department of Obstetrics and Gynecology and Bates professor of diseases of women and children at the University of Michigan.
According to the 2022 KFF Women’s Health Survey, 29 percent of American women ages 18-64 who have seen a health care provider in the past two years felt their doctor dismissed their concerns, compared with 21 percent of men.
Fifteen percent of women report that a provider did not believe they were telling the truth, 19 percent say their doctor made assumptions without asking, and 13 percent say that a provider suggested the patient was at fault for their health problem.
Missing Part of the Picture
In addition to being ignored and dismissed in the clinic, women and their health problems have also been historically pushed aside in clinical trials.
In recent decades, researchers have worked to make clinical trials more representative to better assess sex differences in the effects of drugs and medical treatments. June 10 marked the 30-year anniversary of the National Institutes of Health Revitalization Act, which mandates the inclusion of women in federally funded research.
By 2014, about half of all participants in clinical trials funded by the NIH were women.
In 2016, the NIH adopted a policy requiring that sex as a basic variable (called SABV) “be factored into research designs, analyses, and reporting in vertebrate animal and human studies. Strong justification from the scientific literature, preliminary data, or other relevant considerations must be provided for applications proposing to study only one sex.”
But a 2022 study that examined drug trials and more than 300,000 trial participants between 2016 and 2019 found inequities in three large areas: cardiovascular disease, psychiatric disorders, and cancer.
While 49 percent of people with cardiovascular disease are women, only 41.9 percent of participants in cardiovascular trials are female. Fifty-one percent of cancer patients are women, but only 41 percent of cancer trial patients are female. And most notably, 60 percent of people diagnosed with psychiatric disorders are women, but just 42 percent of participants in research for psychiatric drugs are female.
Women of color are especially underrepresented in trials, in part because there is a well-earned distrust of the medical community among Black and brown women, says maternal and fetal medicine physician D’Angela Pitts, director of maternal health equity at Henry Ford Health.
In just the last century, there has been forced sterilization of women of color, as well as the well-known case of Henrietta Lacks, a Black woman whose cervical cancer cells were harvested without her consent for decades of ongoing study.
“There are disparities in women’s health care, but I think it takes it a step further for women of color since there is history of distrust in the health care system,” Pitts says. “It’s led to difficulties in getting people to participate.”
Missed Opportunities in Funding
At the core of the disparities is a glaring issue that reverberates throughout science and medicine: Researchers have found that in nearly three-quarters of the cases where a disease is most commonly found in one sex, a disproportionate amount of money goes to those diseases that affect more males than females, and the opposite for the diseases that affect more females than males.
In an analysis of cancer funding, using data from the U.S. National Cancer Institute from 2007 to 2017, researchers found that gynecological cancers receive less monetary support than others — out of 19 cancers, ovarian cancer ranks fifth for “lethality” (years of life lost per diagnosis) but receives significantly less NIH funding than other diseases, including prostate cancer. A similar comparison was found for cervical cancer.
Endometriosis — a chronic disease in which tissue similar to the lining of the uterus grows outside the uterus and can cause debilitating pain — affects roughly 10 percent of women and girls of reproductive age globally.
Yet in 2022, the expected funding for endometriosis from the NIH, the largest source of biomedical research funding, was $16 million — only about 0.04 percent of the budget.
“There are conditions like endometriosis which are highly prevalent, benign conditions that aren’t associated necessarily with mortality but are absolutely associated with extreme amounts of morbidity and negatively impacting quality of life,” says Dr. Erica E. Marsh, professor of obstetrics and gynecology at the University of Michigan Medical School and chief of reproductive endocrinology and infertility.
“It’s frustrating as a researcher and a woman that these disparities in funding exist. But we keep advocating, we keep submitting, we keep publishing, and we partner with the most powerful voice out there, which is the voice of the patient, to keep these issues at the forefront.”
The same issues exist for other similar conditions. It is estimated that up to 77 percent of women will at some point develop fibroids, noncancerous tumors that grow in the wall of the uterus that can lead to serious pain and a host of problems.
In 2019, fibroid research received about $17 million in NIH funding — making it one of the bottom 50 of 292 funded conditions.
Black women are more prone to developing fibroids than any other racial or ethnic group.
“We’re taught periods are supposed to hurt,” Pitts says. “But [for] women with conditions like endometriosis or fibroids, it’s not just a painful period.”
The consequences of underfunding are far-reaching. Not only does it mean less is known about conditions that affect women, but those areas in turn attract fewer aspiring scientists, Fenner says.
“When you have really bright, talented young investigators looking at a field they want to go into and study, they’re naturally going to want to go where the money is. Getting tenure at universities is related to how much funding you can get,” Fenner says. “It’s a system that feeds itself that prevents expansion of research in women’s health.”
Locally, there are some big NIH funding recipients for women’s health. The Michigan State University College of Human Medicine’s Department of Obstetrics, Gynecology and Reproductive Biology is one of the most well-funded research institutions. Among departments at 66 universities around the country, MSU’s OB-GYN department ranked fourth in 2022, with $12,699,996 in grants from the NIH.
Paying the Price
The implications of these disparities are vast. According to a report by the nonprofit Women’s Health Access Matters, women are 50 percent more likely than men to die in the year after a heart attack, and nonsmoking women are three times as likely to get lung cancer than nonsmoking men. Women account for 78 percent of the Americans who have an autoimmune disorder as well as 66 percent of all Alzehimer’s patients.
And the consequences extend even beyond health. It is estimated that if the NIH doubled its funding for three conditions that disproportionately affect women — Alzheimer’s disease and other dementias, coronary artery disease, and rheumatoid arthritis — the country’s cost savings over 30 years would be $932 million, $1.9 billion, and $10.5 billion, respectively.
In the meantime, those who study women’s health are looking to other funding sources like philanthropic foundations and seed grants.
“Women’s health disparities are multipronged and come in many different shapes, forms, and sizes across many different areas,” Fenner says. “Many of us are fighting for [equity in funding], but it’ll be several decades, at best, before this changes.”
This story is from the October 2023 issue of Hour Detroit magazine. Read more in our digital edition.