Pendleton A, McBay B, Patella S. The association of patient race and ethnicity with risk of hysterectomy for severe postpartum hemorrhage: a review of current literature. HPHR. 2021;34.
Postpartum hemorrhage (PPH) is the most common cause of maternal morbidity and mortality worldwide. While many treatment modalities exist for PPH, hysterectomy is a last-resort surgical procedure for mothers in extremis. Hysterectomy is an invasive procedure that may be associated with profound psychological consequences for patients. Given the significant sustained disparities in maternal health outcomes among non-white, and specifically Black, individuals in the United States, there exists the potential for racial inequity in hysterectomy rates for mothers suffering from PPH. The primary aim of this review was to examine hysterectomy rates among individuals with PPH stratified by race and ethnicity.
This review utilized a MeSH search strategy of publications available through PubMed. Publications were analyzed independently by three researchers for inclusion in the review. The primary outcome analyzed was hysterectomy rates for PPH stratified by patient race.
The search returned 123 results, of which 7 met inclusion criteria in the review. The majority of studies (5 out of 7) examined patient populations within the United States, and all studies were conducted in high-income countries (USA, Germany, and the UK). The seven studies were published between 2006 and 2020, and the number of deliveries included within each study ranged from 59,790 to 55,214,208 deliveries. All seven studies found statistically significant differences in rates of peripartum hysterectomy as a factor of race/ethnicity. Four studies conducted within the United States examining differences in hysterectomy rates between non-Hispanic white patients and Black, Asian or Pacific Islander, and Hispanic patients found that Black women were significantly more likely than non-Hispanic white women to undergo hysterectomy for PPH. Three studies found increased risk of peripartum hysterectomy for Hispanic patients as compared to non-Hispanic white patients. Considering Asian or Pacific Islander patients, four studies demonstrated increased risk of peripartum hysterectomy for this patient group as compared to non-Hispanic white patients. Regarding results from the two studies that compared immigrant patients with native-born patients, both found results indicating that immigrant patients experienced higher rates of hysterectomy for PPH as compared to patients born in the UK and Germany, respectively.
This review found that in all 7 studies, hysterectomy rates for PPH were higher among non-white persons. The review highlights the scarce body of literature examining racial disparities in treatment modalities for PPH, suggesting this as a critical area for further research.
The Black Lives Matter (BLM) resurgence during the summer of 2020 has renewed attention towards many of the disparities faced by people of color. When evidenced in medicine and healthcare, such as in forced sterilizations, gynecologic procedures performed without consent, or starkly elevated maternal mortality rates in individuals of color, these disparities are particularly “shocking and inhumane”.1 In the United States, Black cisgender women over 30 years of age have 4 to 5 times the pregnancy-related mortality ratio of white cisgender women.2 Even before the 2020 BLM movements, high-profile cases such as that of Serena Williams’ struggle to have her symptoms be taken seriously during her pregnancy reminded us that Black women cannot out-study, out-earn, or out-perform the impact that their skin color has on the biases influencing maternal healthcare.3
Postpartum hemorrhage (PPH) is the most common cause of maternal morbidity and mortality worldwide, responsible for over one-third of maternal deaths each year.4 Black women and pregnancy-capable individuals have a significantly higher risk of PPH as compared to their white counterparts in the United States.5 Additionally, Black individuals who develop PPH are at higher risk of severe morbidity and mortality.2,6 Treatment modalities for severe PPH include medical management, uterine balloon tamponade (UBT), uterine artery ligation, and hysterectomy.7 Hysterectomy is an invasive, non-reversible procedure that is appropriate as a life-saving intervention when other treatment modalities have failed.8 Hysterectomy for postpartum hemorrhage remains a last-resort intervention, as the procedure is associated with permanent physical changes as well as profound psychological consequences for patients.9–12 Additionally, this surgical procedure is shadowed by a horrific legacy of use as a non-consensual sterilization tool for women of color across the world.13,14
Before choosing to complete a hysterectomy, clinicians progress through several levels of decision making. This progression introduces significant opportunity for implicit and explicit biases to influence decisions at each level. Individuals of color frequently fall victim to the consequences of these negative biases.15 Using an ecosocial framework, which views negative health outcomes as a result of a network of oppressive societal factors and biases, we sought to evaluate whether Black women are at risk for receiving hysterectomies more often than white women as treatment for severe PPH.16
The primary aim of this work was to determine whether patients’ race or ethnicity was associated with treatment modality in cases of refractory postpartum hemorrhage (PPH) through a review of the existing literature. Specifically, this work examined whether non-white individuals were at higher risk for undergoing hysterectomy for severe PPH.
The primary outcomes analyzed were rates of hysterectomy for individuals diagnosed with PPH stratified by race.
PubMed was searched for publications using medical subject heading (MeSH) terms developed with the assistance of the Harvard Library Countway librarians to capture the outcome of interest (Figure 1). The search was not restricted by year.
((((post-partum[tiab] OR postpartum[tiab]) AND (haemorrhage[tiab] OR hemorrhage[tiab] OR blood loss[tiab] OR heavy bleeding[tiab])) OR PPH[tiab]) AND (uterine atony[tiab] OR retained placenta[tiab] or placental abnormalit*[tiab] OR coagulopath*[tiab] OR placenta accreta[tiab] OR “Postpartum Hemorrhage”[Mesh] OR “Uterine Hemorrhage”[Mesh])) AND (Race[tiab] OR racial[tiab] OR racism[tiab] OR racial[tiab] OR ((People[tiab] or person*[tiab]) AND of color[tiab]) OR POC[tiab] OR people of color[tiab] OR Non-white*[tiab] OR nonwhite*[tiab] OR ethnic[tiab] OR ethnicity[tiab] OR ethnicities[tiab] OR Black*[tiab] OR Hispanic*[tiab] OR Latin*[tiab] OR Latin American*[tiab] OR Mexican*[tiab] OR Dominican*[tiab] OR Haitian*[tiab] OR Asian*[tiab] OR Hmong[tiab] OR Vietnamese[tiab] OR Native American*[tiab] OR American Indian*[tiab] OR pacific islander*[tiab] OR Native Hawaiian*[tiab] OR African-American*[tiab] OR African descent[tiab] OR African origin[tiab] OR indigenous[tiab] OR native*[tiab] OR Indian*[tiab] OR “Social Segregation”[Mesh] OR “Population Groups”[Mesh] OR “Vulnerable Populations”[Mesh] OR “Continental Population Groups”[Mesh] OR “Ethnic Groups”[Mesh] OR “Minority Groups”[Mesh])
Figure 1. Search term string
Papers returned by the search strategy were screened for inclusion by three reviewers (one reviewer per article) per the inclusion and exclusion criteria detailed in Figure 2.
➢ Articles published and available in PubMed prior to November 15, 2020
➢ Articles described the proportion of patients that underwent emergency hysterectomy for severe PPH
➢ Results were stratified by patient race and/or ethnicity
➢ Non-English publications
➢ Studies not performed in humans
➢ Case reports, commentaries, duplicate articles, and studies for which the full text was unavailable
Figure 2. Review inclusion and exclusion criteria
All papers that met inclusion criteria were subsequently reviewed by a single reviewer to ensure consistency and appropriateness for inclusion within this review.
The following data were abstracted from included studies using a data collection form designed a priori collaboratively by the three reviewers: number of patients included within the study, study design, date of publication, country of study, races/ethnicities by which the study stratified PPH treatment modalities, and treatment outcomes by stratified by race/ethnicity. All included studies were evaluated using the Joanna Briggs Institute (JBI) Critical Appraisal Tool Checklist for Cohort Studies.17 This tool uses 11 appraisal checkpoints to assess the methodological quality of studies and determine the risk for bias in design, conduct, and statistical analysis.17
In total, the search returned 123 results, of which 7 met criteria for inclusion in the review. Characteristics of these papers are included in Table 1. The majority of studies examined patient populations within the United States (5 out of 7 studies), and all studies were conducted in high-income countries (USA, Germany, and the UK). The number of deliveries included in each study ranged from 59,790 to 55,214,208.18,19 Not all publications included the PPH rate for the overall population, but two publications (both conducted within the United States), cited overall sample PPH rates of 2.14% and 3.2%, respectively.20,21 Though some papers limited calculations only to hysterectomy performed secondary to PPH from uterine atony, other papers included all peripartum hysterectomies performed (potentially including hysterectomies performed for fibroids, placenta accreta, or another indication).20,22 Per the JBI checklist, 4 studies met all 11 criteria, 2 met 10 criteria, and 1 study met 7 criteria, indicating low risk of bias in the design, protocol, and statistical analysis for the majority of studies included in this review.17
There was significant variation in the specific racial/ethnic categories compared within each study. Four studies, all conducted using databases from US patients, examined differences in hysterectomy rates between non-Hispanic white patients and Black, Asian or Pacific Islander, and Hispanic patients.19–21,23 One study specifically compared Caucasian patients with Asian American and Pacific Islander patients (terminology used to describe racial/ethnic categories taken directly from source papers).24 Two publications compared hysterectomy rates in patients born within the country of study to hysterectomy rates within specific immigrant patient populations: namely, patients born within Germany as compared to migrants from Asia and Africa/Latin America/other countries, and patients born within the United Kingdom to patients born within Africa.18,22
All seven studies found statistically significant differences in rates of peripartum hysterectomy based on race/ethnicity. Four of the five studies conducted in the United States examined differences in hysterectomy rates using the following racial/ethnic categories: non-Hispanic white, Black, Asian or Pacific Islander, and Hispanic.19–21,23 These studies found that Black women were significantly more likely than non-Hispanic white women to undergo hysterectomy for PPH.19–21,23 These studies also reported that Black patients suffering from PPH had a hysterectomy rate of 2.9% as compared to 1.9% for white patients in cases of severe PPH, had an increased adjusted risk ratio for hysterectomy of 1.35 as compared to white patients, had a peripartum hysterectomy rate of 111.0 per 100,000 hospitalizations for Black patients as compared to 75.7 per 100,000 for white patients, and had a higher rate of hysterectomy performed for PPH from uterine atony (4.0 per 10,000) as compared to non-Hispanic white patients (2.8 per 10,000).19–21,23 Three studies found an increased risk of peripartum hysterectomy for Hispanic patients as compared to non-Hispanic white patients: Friedman et al. found an adjusted risk ratio of 1.19 for Hispanic patients as compared non-Hispanic white patients, Lawson et al. found an adjusted OR of 1.18, and Bryant et al. found a rate of 4.0 hysterectomies per 10,000 cases of PPH from uterine atony as compared to 2.8 per 10,000 cases.19,20,23 Considering Asian or Pacific Islander patients, four studies demonstrated increased risk of peripartum hysterectomy for this patient group as compared to non-Hispanic white patients.20,21,23,24 These studies found that the rate of hysterectomy for PPH among Asian or Pacific Islander patients was 2.4% as compared to 1.9% among non-Hispanic white patients and 1.2% among Caucasian patients.20,21,23,24 These studies also found a rate of 119.6 peripartum hysterectomies per 100,000 hospitalizations for Asian women as compared to 75.7 per 100,000 for white women, and a rate of 5.2 hysterectomies per 10,000 cases of PPH from uterine atony for Asian patients as compared to 2.8 per 10,000 for non-Hispanic white patients.20,21,23,24
Regarding results from the two studies that compared immigrant patients with native-born patients, both found results indicating that immigrant patients experienced higher rates of hysterectomy for PPH as compared to native-born patients.18,22 Reime et al. found that migrants from Asia (adjusted odds ratio 3.57) and Africa/Latin America/other countries (adjusted odds ratio 2.60) had higher odds of hysterectomy for PPH as compared to women born within Germany.22 Interestingly, there was no statistically significant difference in rates of hysterectomy for women migrating from Western countries, Mediterranean countries, or Central/Eastern Europe as compared to women born within Germany.22 Finally, a study conducted by Yoong et al. found that over a 20-year period (1983 to 2003), “nearly half” of the 18 emergency hysterectomies performed for PPH at a district hospital affiliated with the University of London were performed in women born in Africa.18 Notably, African-born women represent only 18% of the pregnant population in this hospital’s region, indicating increased risk of hysterectomy for this specific patient population.18
While the consistent rise of severe maternal morbidity and maternal mortality in the United States over the past 25 years is well characterized, the persistence of racial and ethnic disparities underpinning this trend remains under-discussed in the discourse.25 Among sustained disparities has been the higher incidence of PPH among non-Hispanic Black individuals.21 Few studies have assessed PPH treatment modalities stratified by race and ethnicity. The aim of this review was to use existing literature to determine if patients’ race and ethnicity is associated with treatment modality in cases of PPH, specifically examining whether non-white individuals were at higher risk of undergoing hysterectomy than their white peers. Of the 123 publications identified through a MeSH search strategy, only 7 papers met inclusion criteria. All 7 publications demonstrated significantly higher rates of peripartum hysterectomy among non-white groups to treat PPH.
The generalizability of these findings is limited by several factors. Of the publications that met inclusion criteria, all studies were conducted in high-income countries (HICs). The lack of data specific to lower middle- and lower-income countries (LMICs and LICs, respectively) is striking, given that LMICs and LICSs experience higher rates of maternal mortality and severe maternal morbidity.7 Data made available in the included publications did not comprehensively include information regarding clinical capacity of hospitals (e.g. on-site interventional radiology or critical care service capacity), which could plausibly impact the availability of PPH treatment modalities and treatment algorithms.
Remaining gaps include, but are not limited to, questions regarding PPH treatment modalities in LMICs and LICs, the influence of structural factors on the availability of different treatment modalities, and how access to different treatment modalities differs by race and ethnic groups. Additionally, the provider clinical decision-making process regarding the choice to proceed with hysterectomy was not assessed by the studies included in this review. Greater understanding of the patient and clinical factors that directed surgical intervention is needed to understand how racism, manifested through explicit and implicit biases, impacts the decision to perform an emergency hysterectomy.
Several of the articles included in this study performed analyses adjusting for risk factors such as obesity, multiparity, household income, and insurance status. These factors are profoundly influenced by the embodiment of structural racism embedded within healthcare systems, income inequities, housing status, and sociopolitical institutions.16 Controlling for factors that are the sequelae of racist institutions, systems, and policy may in fact underestimate the association of race on hysterectomy rates, underrepresenting the impact of racism in these studies.
Future research should characterize how race and ethnicity may be predictive of PPH treatment modality given the context of sustained disparities in maternal morbidity and mortality in non-white persons. The findings of this work suggest the need for both surveillance initiatives and structured protocols to ensure that emergency hysterectomies are performed equitably across patient populations. Additionally, the need for a validated PPH severity tool to better contextualize cases of PPH and their subsequent interventions is warranted.
The findings of this work cannot be divorced from the broader social history regarding forced sterilization and reproductive control. In the United States, Black, Hispanic, and other minority communities have long been the target of state-sanctioned and institutionally-permitted sterilization, wielding hysterectomies and tubal ligations as means of social control and robbing countless individuals of their reproductive capacity.13,26 While “Mississippi Appendectomies” of the early twentieth century and lawsuits like Madrigal v. Quilligan of 1978 are considered hallmarks of the history of forced sterilization in the United States, recent whistleblower accounts of non-consensual hysterectomies in Immigrations and Customs Enforcement (ICE) detention facilities in Georgia reveal the endurance of this practice well into the present day.27 The higher rates of hysterectomies among non-white racial and ethnic groups perhaps serve as further evidence that the use of hysterectomies as a means of social control wielded against racial and ethnic minorities is not a racist artifact but rather an ongoing practice tantamount to events that define the legacy of eugenics in the United States. As such, reproductive justice and public health-oriented frameworks must be employed to address this as a sociomedical issue and matter of deep social injustice.
To address the highlighted disparities, investment in further research and evidence-based solutions is needed. Institutional compulsory reporting of emergency hysterectomy rates stratified by race and continued surveillance of this data is critical to understanding how this disparity persists at the institutional level. Additionally, the development of and adherence to protocols safeguarding the informed consent process for hysterectomies is essential, with appropriate discussion of risk even in emergency situations. Potential avenues for future research should include qualitative analyses of provider rationale for proceeding with emergency hysterectomy to assess and address implicit bias. These proposed solutions are by no means exhaustive, but represent potential actions to safeguard the reproductive agency of Black and other minority individuals.
In summary, a literature review revealed a relatively scarce body of work suggesting rates of hysterectomy are higher among non-white persons for the treatment of PPH. The need for further research on the topic is essential in light of persistent racial and ethnic disparities in maternal morbidity and mortality.
Table 1. Included study characteristics. Studies sorted by publication year
Summary of Results
JBI Critical AppraisalA
The association between race/ethnicity and peripartum hysterectomy and the risk of perioperative complications23
Peripartum hysterectomy rates were lower in white women (75.7 per 100,000) as compared to HispanicB (104.7 per 100,000), Asian (119.6 per 100,000), and Black (111.0 per 100,000) women. After adjusting for demographic, clinical, socioeconomic, and hospital level factors, Hispanic women had a higher odds ratio of hysterectomy as compared to white women (OR 1.18).
Postpartum hemorrhage outcomes and race21
Black women and Asian or Pacific Islander women were more likely than non-Hispanic white women to undergo hysterectomy (2.9% and 2.4% respectively vs 1.9%, P < .01).
– Analysis adjusting for confounding factors for hysterectomy as the primary outcome is absent
Increased perinatal morbidity and mortality among Asian American and Pacific Islander women in the United States24
Asian American and Pacific Islander women were more likely than Caucasian women to undergo hysterectomy (1.2% vs 0.8%, p<0.001).
– Analysis adjusting for confounding factors for hysterectomy as the primary outcome is absent
based risk for peripartum hysterectomy during low- and moderate-risk delivery hospitalizations19
In adjusted log-linear regression models, Black and Hispanic patients had increased adjusted risk ratios of hysterectomy as compared to white, non-Hispanic patients (ARR 1.35 and 1.19 respectively).
The association of maternal race and ethnicity and the risk of postpartum hemorrhage20
Non-Hispanic white patients had a lower risk of PPH from atony resulting in hysterectomy (2.8 per 10,000) as compared to African American (4.0 per 10,000), Hispanic (4.0 per 10,000), and Asian/Pacific Islander (5.2 per 10,000) patients (p<0.001).
Maternal near-miss among women with a migrant background in Germany22
After adjustment for maternal age, occupational status, parity, smoking, prenatal care, chronic conditions, and infertility treatment, migrants from Asia (AOR 3.57) and Africa/Latin America/Other countries (AOR 2.60) had higher odds of hysterectomy as compared to women from Germany.
Obstetric hysterectomy: changing trends over 20 years in a multiethnic high risk population18
Of 18 total hysterectomies, nearly half were performed in African-born women, who represent only 18% of the pregnant population in the study’s population.
– Baseline characteristics of the two populations (African-born women vs non) are not provided
– Confounding factors are not identified
– Analysis adjusting for confounding factors for hysterectomy as the primary outcome is absent
– No statistical analysis tested emergency hysterectomy rates in African-born women vs non
A Joanna Briggs Institute Critical Appraisal Tool Checklist for Cohort Studies number of requirements met (out of a total of 11)17
B All race/ethnicity terminology in this table is as written in each source publication
Alaska Pendleton is a Vascular Surgery resident at Massachusetts General Hospital. Originally from Wisconsin, she earned a BS from the University of Wisconsin-Madison in Biochemistry and German and her MD from Harvard Medical School. She is currently earning a MPH from the T.H. Chan School of Public Health, and is a research fellow with the Harvard Program for Global Surgery and Social Change.
Brandon McBay is a Master of Public Health candidate in the Department of Social and Behavioral Sciences at the Harvard T. H. Chan School of Public Health. Brandon’s professional experience has largely been in the clinical research space, having worked as a Clinical Trials Associate with the Center for Emergency Care Research and Innovation at Vanderbilt University Medical Center. He is a graduate of Vanderbilt University’s College of Arts and Science where he studied Medicine, Health, & Society and Women’s & Gender Studies
Samantha Patella, BA, is with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health.