The Intersection of Structural Racism and Health Services Research in Characterizing the Epidemiology of Uterine Fibroids
Authors: Mya L. Roberson
Journal: JAMA Network Open (2024)

This study by Langton et al 1 explores the association between maternal family history and the development of uterine fibroids among a cohort of Black women who were fibroid-free at baseline.By ascertaining maternal fibroid history through direct surveying of the mothers, Langton et al 1 provide a more robust assessment of family history of fibroids than has been captured previously using variable methods.Despite this enhanced method, this investigation by Langton et al 1 offers a critical example of how structural racism intersects with health services delivery that affects the fundamental epidemiologic understanding of a medical condition disproportionately experienced by Black women.At its most essential level, the field of epidemiology involves the counting of incident occurrences of a disease or health outcome.However, for conditions like uterine fibroids, the counting of cases cannot be isolated from the systemically racist history of reproductive health care in the US. 2 The field of obstetrics and gynecology has its origins in the exploitation of and experimentation on Black and poor women, with the vestiges of this troubled legacy impacting gynecologic care delivery today. 3By modern standards, Black women have less access to highquality reproductive health care, which can influence the detection and diagnosis of gynecologic conditions, like uterine fibroids.When diagnosed, Black women are known to have higher incidence rates of uterine fibroids than other women and are more likely to be diagnosed at younger ages. 4,5 Prior work has qualitatively and quantitatively described experiences of racial discrimination and dismissal of symptoms among Black women with uterine fibroids. 6 their study, Langton et al 1 found that having a positive maternal history of fibroids greatly increased the risk of incident fibroid development in adult daughters.Importantly, Langton et al 1 also found that 24% of potential participants entering the cohort believed themselves to be fibroid-free but were found to have fibroids in ultrasonographic examination.Therefore, while directly surveying the mothers represents an improvement over prior family history methods, it likely remains an underestimation of true maternal disease burden that exists.The presence of a mother reporting a fibroids diagnosis represents a particularly high level of access to health care that emphasizes the complex associations between health care delivery and epidemiology for conditions like uterine fibroids.While the detection of fibroids on cohort entry was incidental to the main study findings, 1 it highlights the substantial underdiagnosis of uterine fibroids in Black women, which may suggest an overall underascertainment of the magnitude of racial inequities that exist for uterine fibroids at a population level. 7en considering the epidemiologic burden of disease, it must be interrogated whether the absence of a diagnosis truly reflects the absence of a disease.In understanding the population-level burden of disease for conditions like uterine fibroids we must ask ourselves who, and what counts?Epidemiology does not exist in a sociopolitical vacuum, underscoring the need for multiple domains of expertise in characterizing disease burden.