If a woman drops to the ground in public experiencing a cardiac arrest, studies show, bystanders are less likely to come to her aid and perform CPR. Why? Breasts.

That gender disparity — just one obstacle when it comes to improving women’s heart health, experts say — has led to the creation of so-called Womanikins: attachments for manikins (the term used for CPR training dummies) so that they look more like women.

Experts say that better training of the public on CPR could help increase survival for those who have cardiac arrest in a public setting, when it’s often up to bystanders to intervene. And addressing disparities that exist between men and women, along with cultural or neighborhood disparities, is an important step, said Dr. Marina Del Rios Rivera, associate professor of emergency medicine at the University of Illinois at Chicago.

Del Rios Rivera works with the American Heart Association and with a statewide project, Illinois Heart Rescue, to improve survival rates for out-of-hospital cardiac arrests.

“If someone receives CPR (after a public cardiac arrest), their chance of survival can double or triple,” she said, adding that rates in Illinois for an out-of-hospital cardiac arrest have gone from 4% to 11% since the project began in 2012.

Often the window of time is so short when someone stops breathing that waiting until paramedics arrive can be too late, said Del Rios Rivera. So in the event of a public cardiac arrest, strangers need to act.

But men are more likely to get that help. One study showed that women are 27% less likely than men to receive CPR from bystanders after a public cardiac arrest, and other studies found that’s due to hesitancy, mostly on the part of men, to touch women’s chests for fear of sexual harassment claims.

“It’s a culture change,” Del Rios Rivera said. “I think that women’s bodies, for a very long time, have been very much objectified and sexualized. There’s this fear of undressing a person in public. There’s this fear of, ‘Am I going to get blamed for molesting this person?’”

“At the end of the day, what people need to consider is, if you don’t act, this person is going to die,” she added.

That’s why CPR education is essential and should address gender disparity, according to Del Rios Rivera. Chest compressions focus on the sternum, not the breasts, and can be done over clothes unless someone is also using a defibrillator, she said. To further familiarize people with proper CPR, manikins should more accurately reflect the anatomy of a woman, she said.

While still rare, recent studies and talk of CPR gender disparity have led to the creation of vestlike attachments that make traditional CPR manikins look as if they have breasts.

New York ad agency Joan Creative and the organization The United State of Women helped develop the so-called Womanikin, a fabric attachment for manikins. Plans are available on its website for those who conduct CPR training to make their own.

Naperville, Ill., teen Vivian Zhao, a senior at Naperville Central High School, has made that a reality at her school. After reading about bystander CPR rates for women and the Womanikin, she formed the nonprofit All Hearts Matter, which has raised more than $1,000 since last summer.

“I started realizing this issue is present at our own school because the manikin is considered unisex, but you can’t really have a unisex manikin,” she said.

By law, all Illinois high school students must receive CPR education. At Naperville Central, it’s a unit within physical education classes, where students, usually freshmen, are able to practice CPR and, if they choose, eventually become certified, said Instructional Coordinator Chair Neil Duncan.

Through her nonprofit, Zhao, 18, enlisted the help of Monica Hernandez, a family and consumer science teacher at Jefferson Junior High in Naperville, to produce fabric attachments simulating breasts, similar to the Womanikin, for Zhao’s own school’s CPR manikins. The group then provided the attachments to Glenbard North High School, and it is starting to make some for Naperville North High School, Zhao said. She’s also reaching out to students at other schools, so they can carry on the effort.

“It’s kind of brilliant,” Dr. Holly Andersen said of the Womanikin attachments. Andersen is medical director of the Women’s Heart Alliance and an associate professor of medicine and director of education and outreach at the Ronald O. Perelman Heart Institute at New York Presbyterian Hospital/Weill Cornell Medical Center.

Adding an attachment is much more affordable than replacing an entire manikin with one that already has a female anatomy, Andersen said.

Improving CPR education can help bystanders feel more comfortable and ultimately save lives, she said. “Instead of recoiling in fear, we want to arm people with very simple messaging.”

Despite an outcry and education from medical organizations, people still don’t realize the toll heart disease has on women, Andersen said. It’s the leading cause of death in both men and women, and rates are on the rise, particularly for younger women, she said. A recent study showed sudden cardiac death is increasing in women.

CPR training is one way to help prevent these deaths, as well as promote awareness of heart disease in women, Andersen said, adding that cardiac arrest can be the first symptom.

Sometimes women feel pain in areas other than the chest as a symptom, or might experience other symptoms, like exhaustion, indigestion or just feel that something is wrong, Andersen said. And regardless of whether or not their symptoms are classic or nontraditional, women tend to delay seeking treatment and are less likely to call 911, she said.

But “even if you control for all of those things, a woman is still more likely to die than a man,” she said. “And we don’t know why, because most of the research has been done on men.”

As organizations continue to do outreach and education, public CPR education is one way to help, Andersen said, pointing to materials from the Hands Only CPR initiative.

“Women don’t talk about heart disease the same way they talk about breast cancer,” she said. “They feel as though they might be judged. There is a stigma that women have that men don’t seem to have.”

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