An unnecessary focus on racialized pelvic stereotypes

AOGS interest in publishing original research from low-resource settings is appreciated. Using serial intrapartum examinations of laboring women in Moshi, northern Tanzania, Bagandanshwa et al. demonstrate the association persistent fetal occipito-posterior (OP) position has with prolonged labor, and a higher incidence of operative (almost exclusively cesarean) deliveries.¹ However, there are some interpretations and assumptions that should be scrutinized.

The introduction draws attention to the high incidence of persistent OP position in the population studied, compared to “white”/“European” parturients. The authors explain that the observed difference is by virtue of the single ethnicity of their study population being “black African women,” and that the anthropoid-shaped pelvis is more common in “Black African women.” The supporting radiological investigation cited is a study by Handa et al., studying magnetic resonance imaging (MRI) to compare pelvic dimensions in a sample of (self-reporting) African-American and white women. However, Handa states not to “use previously described categories to classify pelvic type in our research because those categories are founded on qualitative comparisons rather than quantitative measures.” Though differences observed between 40 racialized female cadavers in South Africa are cited, ignored is the study that finds one single anthropoid pelvis among 47 South African Zulu parturients.² No other pelvic surveys from the African continent are mentioned. Despite literature that casts doubt upon its usefulness,³ Bagandanshwa et al. assume that anthropoid proportions for the entire population of the “black” African continent are equal to the 40% found in the 121 “negro female” skeletons surveyed by Caldwell and Moloy. A questionable assumption, given the “one-drop rule” of racial categorization that operated in the USA prior to 1938, supported by genetic studies demonstrating up to 24% European ancestry among African Americans. Based on mtDNA haplotypes, African Americans share minimal ancestry with East Africans.⁴

The study by Bagandanshwa et al. involves “only one ethnicity.” I question whether this single sample is representative of the several thousand ethnicities within the African continent alone. The greatest genetic variation between groups on the planet is found in Africa.

Bagandanshwa et al. do not provide radiological evidence to support persistent OP position in labor due to the anthropoid pelvic shape alone. Little is offered to the reader regarding the labors conducted at Moshi. Other than the absence of regional analgesia, little is documented regarding the parturient's mobility, doula support, and one-to-one midwifery care, all of which have been shown to reduce complications associated with persistent OP position in labor. No discussion of attitudes and possible biases of the local healthcare providers when managing laboring women with the fetus in a persistent OP position. These may be significant issues to consider when making comparisons with “European” centers.

Perpetuating the racialization of the female pelvis detracts from the qualities of this study. I question whether the focus on racial stereotypes is useful in the clinical setting, given that the study's corresponding author has previously concluded, writing for the online textbook for the Nordic Federation of Obstetricians and Gynecologists (NFOG), that “The pelvic shape cannot be diagnosed clinically nor with ultrasound”.⁵