Black women are almost twice as likely to experience infertility as their white counterparts, but only 8% of Black women seek fertility treatment, compared to 15% of white women. Statistics like these, compounded by the fact that Black women are three times as likely to die from pregnancy-related causes, highlight inequalities in reproductive healthcare that the medical community must address.
The higher incidence of infertility among Black women is due in part to a higher prevalence of uterine fibroids, ovulatory dysfunction, and tubal disease. Studies show that Black women also have higher rates of pregnancy loss, including miscarriages and stillbirths when compared to white women. This is likely because Black women have higher rates of risk factors that are associated with pregnancy loss, such as obesity, diabetes, and low socioeconomic status.
For Black women, the isolation of infertility is compounded by various factors (for example, cultural stigma, socioeconomic barriers, and racial bias) that prevent them from getting the care they need. Those who do end up seeking care often find themselves feeling deeply uncomfortable in the medical space, which is still predominantly white.
Diversity in Healthcare Providers
People of color need to have access to BIPOC (Black, Indigenous, and People of Color) healthcare providers because it provides a sense of comfort and familiarity. This can encourage patients to access available fertility care and can even improve treatment outcomes. BIPOC healthcare providers possess culturally specific knowledge, skills, and experiences that help with communication and health management processes involving people of color.
Diversity in providers also helps reduce barriers to the patient-physician relationship for racial/ethnic and linguistic minority patients. In many situations, seeing someone who looks like you and understands your cultural background offers reassurance.
Many studies have demonstrated better health outcomes when BIPOC providers see patients of color. A result of this is increased trust and communication developed between the patient and provider. The patient may feel more comfortable sharing sensitive information with someone who has an unspoken understanding of what the patient might be going through. Research has shown that Black women who have a provider with a similar cultural history may feel more comfortable speaking up and advocating for themselves.
Many people of color have a (warranted) sense of mistrust when it comes to our healthcare system due to historical practices based on racist ideals. As healthcare providers, we must remain dedicated to bridging the gap to improve outcomes for patients of color.
What Factors Most Impact Black Patients?
Long-held beliefs, stereotypes, cultural stigma, and other issues continue to uphold these racial disparities around fertility and family-building. Here are some examples of the various factors that contribute to widening the gap in care for Black women:
Structural racism: This heavily contributes to racial disparities in fertility and maternal healthcare in various ways, as structural racism goes beyond the individual. It refers to inherently racist laws, rules, economic practices, and cultural and societal norms that are embedded in the system itself.
Implicit or unconscious bias: This occurs automatically and unintentionally, affecting our judgments, decisions, and behaviors. For example, a white doctor might downplay complaints of pain after surgery from a patient of color due to engrained, inaccurate stereotypes about the strength or pain tolerance of BIPOC people, only to discover the patient is genuinely experiencing discomfort.
Accessibility: Many people of color encounter barriers to accessing the healthcare they need due to a lack of insurance or insurance coverage that excludes fertility treatment. Financial roadblocks and accessibility to quality reproductive care are often limited by location (rural or underserved areas may not have fertility clinics nearby) and employment (not everyone can take time off of work to go in for morning monitoring appointments, which are often required during fertility treatment).
The myth of hyperfertility: The long-held myth that Black women (and men) are “hyper-fertile” causes considerable harm, leading to a resulting cascade of issues.
Religious beliefs: Many people in the Black community are taught to “pray your way” through difficult situations. And while it’s wonderful to have faith, sometimes it’s necessary to seek professional help. Trusting that a higher power will correct infertility leads some people to delay or avoid treatment altogether.
Harmful stereotypes: Black women are thought of as being incredibly strong ― and we are ― but when we are elevated to “Superwoman” status and need to take off our proverbial capes to ask for help, we are often judged harshly or perceived as weak.
Mental health: Shame, guilt, or anxiety about how people in our community may react prevents or delays many women of color from seeking infertility treatment. The stigma of mental illness is also a concern when addressing infertility. Many people coping with infertility experience depression, anxiety, and grief, and cultural norms can discourage people from sharing that they are struggling with their mental health.
Isolation: Many people hesitate to talk about their personal experiences with infertility, which often leaves Black women with the impression that they are alone in their struggles or that infertility is a reflection of their character or a personal failing. That’s why sharing fertility stories is so important, especially in communities of color.
Black Maternal Mortality Rates
Many women of color might lack insurance coverage for maternal health or be afraid to advocate for themselves with their doctor. But the starkest evidence of the healthcare system failing people of color is Black maternal mortality rates in the United States, which are alarmingly high.
Studies have shown that Black women are three times more likely to die from pregnancy-related causes than white women. Worse yet, even though multiple factors contribute to this disparity, most are preventable. These factors include access to quality healthcare, underlying chronic illnesses, and two of the most easily preventable: implicit bias and structural racism. As a healthcare system, we need to focus on listening to the concerns of patients of color without allowing unconscious bias to play a role in our treatment decisions.
Responsibility to Patients
In vitro fertilization (IVF) and other fertility treatment options can be very expensive, which makes it exponentially more challenging for individuals with lower median household incomes to afford this path to parenthood. With lower incomes in comparison to white and Asian couples, Black and Hispanic couples may have a hard time affording fertility care if they have to pay out-of-pocket.
Knocking down the roadblock of affordability often goes beyond the scope of the medical community’s responsibility. However, bridging the gap of distrust with people of color and providing culturally competent care does not. One important step hospitals and health systems can take is to increase the diversity of providers within reproductive health specialties. Collectively, we must work to dismantle structural racism, educate ourselves, and listen to people of color. Only then will we start to make progress toward lessening racial disparities in fertility and maternal healthcare.
The North Carolina Nurses Association (NCNA) has spent the past year embarking on a multipronged initiative of self-reflection, intentional listening, and planning a more inclusive version of Nursing Forward. The methodical process culminated in a Racial Reckoning Statement approved by NCNA’s Board of Directors in September.
The statement acknowledges NCNA’s history, apologizes for its past actions, and commits to relentlessly holding itself accountable as a more inclusive association in the future. This represents the first such initiative from any state nurses association.
“NCNA is committed to recognizing where we have fallen short in the past to ensure we do better going forward,” says NCNA President Trish Richardson, MSN, BSBA, RN, NE-BC, CMSRN. “We have been intentional about the process and making sure this isn’t simply ‘checking a box.’ The Racial Reckoning Statement is a vital milestone for the association, but it is not the end of the conversation.”
NCNA convened a Diversity, Equity, and Inclusion (DEI) Values Task Force, charged with developing a values statement, and is appointing a new member of the Board of Directors with past experience with DEI programs. Meanwhile, NCNA worked to educate its members about the association’s history of racism, highlighted by a three-part series in the Tar Heel Nurse membership magazine that was spearheaded by NCNA member and nursing historian Dr. Phoebe Pollitt, RN. Her research shed light on overtly racist actions by the association and its leaders and a decades-long pattern of resistance to integration and inclusivity within NCNA leadership.
The combined efforts stem from NCNA’s newest strategic priority of “Relentless Inclusion,” first championed in 2022 by Immediate Past President Meka D. Ingram, DNP, MSN, RN, NE-BC. The association has implemented strategies and tactics by the American Nurses Association and the National Commission to Address Racism in Nursing. Still, NCNA intentionally made this initiative a stand-alone effort that was developed independently, focusing on North Carolina-specific goals and outcomes.
“Many of the results from this initiative have been disheartening to confront, but I am proud of what we have achieved and optimistic about the real changes NCNA is implementing,” says Ingram. “I am encouraged by my colleagues from across North Carolina who have approached this with the seriousness it deserves and, in some cases, had their minds changed about why this type of work is incredibly important.”
NCNA solicited feedback during the Statewide Membership Forum at its Annual Convention and via member surveys conducted through October 15 to help determine the next steps. Feedback overwhelmingly supports the Racial Reckoning Statement and the overarching initiative. Some anonymous quotes from NCNA members include:
“A humbling document to read, pierced by a ray of hope that the document was finally penned and unabashedly shared with all NCNA members. Nursing Forward.”
“Well written. I think it should also have some language around each individual holding themselves accountable for correcting and preventing the continuation of these wrongs but also hold other nurses accountable not to allow racist behaviors to continue and prevail.”
“Include all minorities, not just African/black Americans.”
“I accept the acknowledgment of racism in the nursing profession, which has been an issue in North Carolina and a national issue. I have been a victim of racism throughout my years as a registered nurse, but I did not allow it to deter me. Yes, I have experienced some bitter and ugly situations. I never allowed racism to control my attitude toward my peers or patients. However, racism did raise its ugly head. I aspired to be the best registered nurse and advance to a higher level of nursing academics. From this time and toward the future, let us move forward with professionalism, diversity, equity, and inclusion.”
“I support this change but am disappointed that NCNA waited until 2022 to speak up.”
“It is admirable that the NCNA would take this opportunity to reconcile the past and present. We cannot go back and change what happened; however, acknowledging the past is huge, even when it is uncomfortable and not the most popular thing to do. I am proud of this action and think this is a great step in moving nursing forward.”
This initiative has been challenging and, at times, painful. NCNA’s Board of Directors also believes it has been well worth the effort and hopes it serves as a catalyst for other nursing and healthcare organizations to be similarly introspective and join NCNA in committing to a more inclusive future for the entire profession.
Many nurses often decide to work in the profession due to their struggles in life, but few are willing to make a difference in their work based on their hardships.
Dr. Sharrica Miller, PhD, RN, has used her voice to speak up against injustice against Black nurses. She’s an assistant professor at Cal State Fullerton, where she serves as chair of Diversity, Equity, Inclusion, and Student Engagement. Miller also owns her consulting firm and works with organizations to implement diversity initiatives.
Miller took the time to answer our questions about her nursing experience and how her beginnings as a foster child inspired her DEI work.
Can you give a brief introduction about yourself?
My life’s journey has been unique and full of challenges. After spending 12 tumultuous years in foster care and emancipating from my last placement in Compton, California, I went to Howard University, where I obtained my Bachelor of Science in Nursing. Let me tell you, it was a struggle! I lacked the academic and social skills to thrive and was lost and overwhelmed when I arrived.
After graduating, I worked bedside for over a decade in various specialties, including pediatrics, critical care, and home health. During that time, I obtained my master’s degree in nursing and most recently graduated from UCLA with my PhD in 2017.
What made you decide to become involved in nursing? Did your upbringing influence your decision to become a nurse?
I needed to make money in foster care to pay for school expenses, so I became a certified nursing assistant at 16. I was still unsure about my future until a family tragedy changed the course of my life. My father was involved in a drive-by shooting my senior year, just a few weeks before I was set to leave for Howard. I’ll never forget the compassionate care the nurses provided to my dad and my family, and from that moment on, I knew that would be my path moving forward.
How does your experience in healthcare influence your roles as a DEI consultant and assistant professor at CSU advocating for inclusive nursing environments?
My first job was in Long Beach in a pediatric rehab center, and I worked with many adolescents who were gang-violent victims. I had the opportunity to work at UCLA as a new grad, but I wanted to be in my community caring for patients who looked like me.
What makes nursing special is that we look holistically at the person in front of us and consider all the circumstances that led them to our care. Thus, having firsthand experience working with diverse patient populations has made me a more experienced DEI strategist and consultant because I learned early on always to remember the person behind the patient.
How have you been able to give back to the foster community? How do you feel when you know you’ve helped them achieve their future goals despite barriers?
Sitting in foster homes as a child, I made big plans about what to do when I grew up and have tried to live up to those goals. My work in the child welfare system has centered on transitional-age foster youth. These young adults between 18 and 26 are emancipating from foster care.
The transition to adulthood is difficult for anyone, but foster youth especially need more skills and resources to navigate the world successfully. I give back to the community by facilitating workshops for child welfare professionals to teach them how to better engage with this population and also by serving as a mentor. It’s a full circle moment when I see my youth succeed. I hope the little girl who made all those plans is proud of me.
What do you value most about your work for diverse nurses?
I value the look on Black nurses’ faces when they finally feel seen. These nurses are on the frontline dealing with discrimination and retaliatory behavior in the workplace, and now they finally see someone calling it out.
What advice would you give younger adults struggling in nursing school or the workplace due to past trauma or microaggressions they’ve experienced?
I would tell them you are the most important person in your life’s journey. You have to affirm, support, and believe in yourself. We tend to go through life looking outward for the answers, but overcoming trauma means getting to know ourselves and building ourselves up.
Dealing with microaggressions requires a different skill set rooted in emotional intelligence. Sadly, many Black professionals, particularly Black women, have to decide if they will stay low or fight for what they believe in. Both have potentially adverse consequences; one hurts our souls, while the other hurts our careers.
My best advice is practical. Build your expertise in various areas and develop multiple income streams to handle a particular employment situation. If you find yourself stuck in a toxic workplace environment, be ready to pivot to the next opportunity.
To learn more about Miller’s work, read her book on the life lessons she learned in foster care or follow her on Instagram at DocMillerSpeaks.
A utilitarian ethical approach views to balance the greatest good over harm to everyone involved while considering the benefits and consequences (Velasquez et al., 2021). Migration occurs when a new circumstance or opportunity is better than the existing situation. The looming shortages in the nursing workforce globally make migration inevitable. It is essential to weigh the benefits and consequences of nurses’ migration.
Nurses can migrate and work in other countries if the country’s visa and employer requirements are met. Frances Hughes, RN, BA, MA, DNURS, FAAN says that nurses in lower-income countries migrate to higher-income countries seeking better career and financial opportunities (Hughes, 2022). Stakeholders directly impacted by the migration process include individual nurses and their families, recruitment agencies, and supplying and accepting countries.
Benefits and Consequences
There are several benefits to migration. Nurses who migrate to higher-income countries are happy with the host countries’ social, financial, and health-related advantages (Hendriks, 2018). One of the greatest benefits of migration is the diversity foreign nurses bring to the workforce. Recruiting foreign nurses also improves the workforce shortage in the host country. A diverse workforce elevates the quality of patient care by ensuring the provision of culturally competent care to a diverse patient population (American Association Colleges of Nursing, 2023). The benefits are not only limited to the host or higher-income countries. The remittance from immigrant nurses financially benefits the supplying countries (Shaffer et al., 2022), families, and individual recruitment agencies.
From a utilitarian view, other consequences of migration are the potential depletion of the workforce in supplying countries due to mass migration and the demand for additional resources by host countries to train foreign nurses to meet the needs of a diverse patient population. It is also important to remember that adapting to a new country and environment could be challenging for individual nurses.
Takeaways: Finding Solutions
The migrating nurses bring cultural diversity, unique knowledge, and skills to the nursing workforce in the host countries (Hughes, 2022). It is unethical to prevent migration considering the overall benefits to the individual, host, and supplying countries. However, a utilitarian cannot ignore the other consequences.
Migrating from one country to another comes with challenges, which vary for individuals from different countries. It is essential to identify the unique needs of foreign nurses and distribute resources in a manner that is easily accessible to avoid waste of resources. Most often, it is not the availability of the resources that is challenging but the need for knowledge in accessing them and finding the best resource that works for each individual—having a common website that provides information on the boarding process, eligibility exam centers, financial support, mentoring, and other essential resources during migration.
Regulated and ethical recruitment practices can be implemented to prevent nursing workforce depletion in supplying countries. From a utilitarian view, it is recommended to ensure transparency on the benefits and consequences of each nurse migration experience for all stakeholders. The availability of information on benefits and consequences will allow better planning and implementation of policies, programs, and resources that support migrant nurses and migration.
References
American Association of Colleges of Nursing. “Enhancing Diversity in the Nursing Workforce.” AACN. April 2023. https://www.aacnnursing.org/news-data/fact-sheets/enhancing-diversity-in-the-nursing-workforce.
Hendriks, Martijn. “Does Migration Increase Happiness? It Depends.” Migration Policy Institute. June 21, 2018. https://www.migrationpolicy.org/article/does-migration-increase-happiness-it-depends.
Hughes, Frances. “Nursing Shortage and Migration: The Benefits and Responsibilities.” CGFNS International. 2022. https://www.cgfns.org/nursing-shortage-and-migration-the-benefits-and-responsibilities/.
Shaffer, Franklin A., Mukul Bakhshi, Kaley Cook, and Thomas D. Álvarez. “International Nurse Recruitment Beyond the COVID-19 Pandemic: Considerations for the Nursing Workforce Leader.” Nurse Leader 20, no. 2 (February 2022): 161–67. https://doi.org/https://doi.org/10.1016/j.mnl.2021.12.001.
Velasquez, Manuel, Dennis Moberg, Michael J. Meyer, Thomas Shanks, Margaret R. McLean, David DeCosse, Claire Andre, Kirk O. Hanson, Irina Raicu, and Jonathan Kwan. “A Framework for Ethical Decision Making.” Santa Clara University. November 8, 2021.
The Diversity, Equity, and Inclusion Leadership Network (DEILN) named Frontier Nursing University Chief Diversity and Inclusion Officer Dr. Paula Alexander-Delpech, Ph.D., PMHNP-BC, APRN, as the network’s Chair-Elect.
DEILN is a convening body to unite expertise, experience, and guidance for academic nursing in Leading Across Differences. This network collectively explores innovative approaches to enhancing diversity, equity, and inclusion in academic nursing and the nursing workforce.
DEILN supports the efforts of the American Association of Colleges of Nursing (AACN) and its more than 865 nursing schools and academic nursing at the local, regional, and national levels to advance diversity and inclusion.
These efforts include, but are not limited to:
Sharing evidence-based promising practices
Engaging with the membership
Providing consultative services
Convening networking forums
“I am honored to have been chosen as the Chair-Elect of DEILN,” says Dr. Alexander-Delpech. “This presents a wonderful collaborative opportunity for all members of DEILN and the institutions we represent to share our knowledge and experience to improve the effectiveness of our collective DEI efforts across the country.”
The goal of DEILN is to align its efforts with the strategic diversity goals and objectives of AACN and the larger nursing community. Membership in DEILN is open to all faculty, deans, and staff interested in advancing diversity, equity, and inclusion goals.
Vanderbilt University School of Nursing Associate Dean for Equity, Diversity, and Inclusion Rolanda Johnson, PhD’98, received the Vanderbilt University Joseph A. Johnson Jr. Distinguished Leadership Professor Award at the university’s Spring Faculty Assembly.
The award recognizes a faculty member who has proactively nurtured an academic environment where everyone feels valued and where diversity is celebrated. It is named for Joseph A. Johnson Jr., the first African American to earn a Vanderbilt bachelor’s degree and the first to earn a doctoral degree.
In recognizing Rolanda Johnson with the award, Vanderbilt University Chancellor Daniel Diermeier says, “Rolanda’s experiences in nursing — as a clinician, educator, researcher, and administrator — inspired her to make a difference in the lives of those who experience health disparities and inequities and are often overlooked. Her passion is educating nurses to better meet the healthcare needs of all populations and delivering high-quality, culturally sensitive care to all patients. Among her efforts at the School of Nursing was advocating for holistic admissions, contributing to more diverse enrollment.”
Johnson has positively impacted equity, diversity, and inclusion on regional, national, and international levels. She serves as membership chair for the Tuskegee University National Nursing Alumni Association, was the inaugural chair of the American Association of Colleges of Nursing’s DEI Leadership Network (DEILN), mentors for the AACN Diversity Leadership Institute, and a member of the American Nurses Association National Commission to Address Racism in Nursing Education Work Group. She co-founded Nashville’s chapter of the National Black Nurses Association. Johnson also served on the U.S. Pharmacopeia Health Equity Advisory Group.
At Vanderbilt School of Nursing, Johnson helps faculty create inclusive curricula and classrooms, offers guidance to student affinity groups, and is exceptionally skilled at recruitment, retention, and inclusion. Her research and scholarship focus on increasing EDI in nursing education and assisting vulnerable populations.
“Most recently, Dr. Johnson co-developed and co-directed the inaugural Vanderbilt Academy for Diverse Emerging Nurse Leaders, a one-week immersive for nurses who have been in leadership roles for less than five years,” says Pamela R. Jeffries, PhD, FAAN, ANEF, FSSH, dean of Vanderbilt School of Nursing. “This was an amazing week for 18 fellows from academia and healthcare systems all over the country. Many described the program as ’life-changing.’ The academy is well poised to be sustainable and in the long-term, will help to mitigate the diversity disparities evident in nursing leadership.”
Senior Associate Dean for Academics Mavis Schorn, PhD, FACNM, FNAP, FAAN, nominated Johnson for the leadership award. “She has advanced equity, diversity, and inclusivity by developing a strategic plan focusing on both recruitment of diverse individuals while also creating a welcoming environment where everyone feels like they belong,” Schorn wrote. “She led the efforts to create a diversity statement for the school and later led efforts to update it to include antiracism language. She has worked with all the admission committees to ensure the admission process is holistic.”
Johnson will carry the Joseph A. Johnson, Jr. Distinguished Leadership Professor title for one year.
“This award was a wonderful surprise,” she says. “I am humbled to receive this honor. While I am the honoree, the VUSN family deserves accolades for ‘WE’ have accomplished much and will continue to be leaders in diversity, equity, and inclusion in nursing and healthcare.”
