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Department of Obstetrics & Gynecology, University of Michigan Medical School, Women's Hospital, Ann Arbor, MichiganDepartment of Health Behavior and Health Education, University of Michigan School of Public Health, Women's Hospital, Ann Arbor, Michigan
). Differential outcomes persist, however, even when pregnant Black women obtain care in high-quality hospitals and when controlling for comorbidities (
Clinicians' implicit bias—unconscious attitudes and beliefs that impact behaviors like body language, tone of voice, receptivity, or decision-making—affects treatment decisions and outcomes (
). In obstetrics, bias may be experienced throughout pregnancy and the postpartum period. For instance, Hispanic women report lower trust in their clinician than other groups, and Black women report worse postpartum pain management (
). One in 10 Black mothers reports they were “treated poorly” because of their identity when hospitalized compared to just 3 in 100 White mothers. Implicit bias can also be rooted in seemingly “evidence-based” practice. Until a recent revision, the widely used Trial of Labor After Cesarean (TOLAC) calculator stratified patients by race and ethnicity based on an observational, not pathophysiologic, basis (
). Commentators note that the lower rates of “successful” TOLAC for Black women in the original validation study may be due to circular logic stemming from biased decision-making by providers, that is, sending Black laboring women to the operating room sooner than their White peers (
). Similarly, race-based correction factors for anemia may bias maternity care clinicians, leading to lower treatment rates of iron-deficiency anemia and explaining the disproportionately high rates of blood transfusions at birth for Black women (
). Many groups, including the Alliance for Innovation in Maternal Health (AIM), the American College of Obstetricians and Gynecologists (ACOG), and the Society of Maternal Fetal Medicine, have made it a priority to reduce maternity care clinicians' implicit bias (
Although implicit bias is widely recognized as a threat to quality obstetric care—and some states, such as California, Illinois, and Michigan, now mandate that clinicians receive implicit bias training—there is little evidence-based guidance for health systems and clinicians on effective interventions (
). Despite these challenges, health systems have an ethical, and sometimes legal, obligation to act because of the urgent stakes for pregnant Black women.
We compiled core concepts present in the literature that can be used to design implicit bias interventions. We propose that three domains are critical: education and self-awareness, communication skills, and cognitive reframing (Figure 1A). We also strongly advocate that patient advisory boards or focus groups be central to the development process and engaged early as collaborators in all domains. Interventions should include all care team members, including physicians, midwives, nurses, social workers, front desk staff, and custodial staff. Although efficacy data within each domain are suboptimal, interventions may have a greater effect when combined. This notion is supported by other obstetric safety and quality improvement initiatives that are enhanced by multidimensional approaches to change (
). Because specific literature on bias intervention in obstetrics is limited, we provide a mixture of evidence from within and outside of obstetrics in this commentary (
Figure 1Domains for change to decrease implicit bias in clinical care. (A) Intervention domains. (B) Communication strategies. (C) Models for patient input. M&M, morbidity and mortality conference. ∗
Precise definitions of implicit bias and increased awareness of one's bias provide a common foundation for change. Educational initiatives should also incorporate cognitive science such as classical conditioning to contextualize interventions (
). Reflective self-assessment tools such as the publicly accessible Implicit Associations Test of Project Implicit can also help participants to understand how implicit bias operates on an individual level (
). Given that some research has demonstrated resistant responses to implicit bias education, expert facilitators can create a nonjudgmental learning culture that promotes receptivity of participants (
). Grand rounds and lecture series can also be used for sharing educational resources that promote self-awareness.
Core concepts
•
Distribute an educational module for developing common definitions that integrates cognitive science. Consider asynchronous modules, lecture series, or didactic sessions to decrease barriers to participation.
•
Use the Implicit Associations Test to help participants understand implicit bias and as a tool for self-reflection.
•
Use expert facilitators who can help participants remain receptive to emotionally challenging content.
Communication Skills
Communication skills are important as they may drive or mitigate the impact of implicit bias (
Detecting implicit racial bias in provider communication behaviors to reduce disparities in healthcare: Challenges, solutions, and future directions for provider communication training.
Patient Education and Counseling.2019; 102: 1738-1743
). This point is especially true in obstetrics care, where patients and clinicians meet frequently over the course of a pregnancy and discuss complex anticipatory guidance. Women of color identify poor information sharing during pregnancy as a locus of constrained autonomy (
). For instance, they describe receiving misleading information meant to influence their decisions and do not feel they are a part of the “the team.” This paternalistic approach experienced by pregnant women of color is in stark contrast with ethical standards of care (
"We'll get to you when we get to you": Exploring potential contributions of health care staff behaviors to patient perceptions of discrimination and satisfaction.
American Journal of Public Health.2015; 105: 2076-2082
). Among obstetrics patients of color, relationship building and sharing information about care, such as treatment options, can reduce perceived discrimination (
). In addition to improving the patient experience, effective communication can mitigate the roots of bias itself. Positive contact between people of different identities can reduce prejudice via empathy, decreased anxiety, and increased perspective-taking (imagining the viewpoint of a member of a stereotyped group) (
Key principles of improved clinician communication such as demonstrating empathy and limiting interruptions should be integrated into all clinical encounters (Figure 1B) (
). Rapport building can be enhanced by connecting on a “social level.” Health systems and individual clinics can provide communications training for clinicians and staff, integrate communications best practices into chart reminders, and prioritize communications skills in hiring and promotion (
Improve patient–clinician communication by using best practices (Figure 1B). This practice may require training as part of undergraduate and graduate medical education, and clinician and staff professional development curricula.
•
Acknowledge perceived bias to help restore a clinical relationship (
Prioritize communications best practices in chart reminders and hiring and promotion decisions.
Cognitive Reframing
Given that implicit bias is an involuntary process, interventions must act on the underlying cognition. This point is important in obstetrics because of clinicians' reliance on cognitive frameworks for decision-making, especially when confronted with high-acuity conditions such as childbirth complications. For instance, Black women are more likely than White women to undergo cesarean section for nonreassuring fetal heart tones (
). Because the interpretation of fetal heart rate tracings allows clinician subjectivity and has poor specificity for neonatal outcomes, this practice provides ample opportunity for clinician bias to impact counseling on timing and indication for cesarean birth (
). Discredited theories about racial differences in pelvic floor anatomy and the TOLAC calculator's prior use of race in predicting outcomes may also have shaped how clinicians counsel patients who are considering vaginal birth after cesarean (
). Because both of these concepts have been standard teachings in obstetrics education until recently, correcting for them will require a concerted effort by each individual clinician.
Only one intervention—a “habit-breaking” model—has been demonstrated to have long-term efficacy in decreasing implicit bias (
). Users of this model recognize when bias may occur and then actively reframe their thoughts through stereotype replacement, counter-stereotypic imaging, individuation, perspective-taking, and increasing opportunities for intergroup contact (Table 1) (
). It has been implemented in medicine, albeit not in an obstetrics context. One academic medical center conducted a 2.5-hour workshop that decreased gender bias in hiring 3 months after the intervention (
). Cognitive reframing can be supported and enhanced with the following three strategies. First, expert facilitators may be used to address clinicians' negative reactions, vulnerability, defensiveness, and avoidance (
in: Mallett R.K. Monteith M.J. Confronting prejudice and discrimination: The science of changing minds and behaviors. Academic Press,
New York2019: 249-274
). Next, integrating a patient's situational, economic, and social circumstances (e.g., housing insecurity) into morbidity and mortality rounds will support reframing clinical decisions (
). Finally, ancillary strategies such as reducing the use of pejorative or depersonalizing language (i.e., “a person with substance use disorder” instead of “addict”) and the use of diverse visual materials for marketing or patient education can reframe how implicit biases impact clinical decision-making.
Table 1Definition of Terms for Habit Breaking Model to Decrease Implicit Bias
Develop trainings using the cognitive science of habit breaking (Table 1). Use expert facilitation to contextualize trainings, create a safe space for growth, and mitigate negative reactions from participants.
•
Integrate perspective-taking and social determinants of health into morbidity and mortality rounds.
•
Support intensive interventions with organizational-culture change, such as integrating diverse images in marketing and patient education and decreasing the use of pejorative or depersonalizing language.
Patient Engagement
Patient engagement is foundational to developing and implementing initiatives to address implicit bias because it centralizes patients’ expertise. Early input can ensure that patients meaningfully inform the intervention and that they are viewed as collaborators rather than tokenized (
"We'll get to you when we get to you": Exploring potential contributions of health care staff behaviors to patient perceptions of discrimination and satisfaction.
American Journal of Public Health.2015; 105: 2076-2082
). The Patient Engagement Panel model is one specific option for patient engagement, with success tied to diverse recruitment, sustainable funding, and benefits to participants such as continuing education and compensation (Figure 1C) (
). Pregnancy-focused groups should consider how to decrease the burden on participants, namely, parents of young children, such as providing childcare and meals at meetings. Potential recruits may have had traumatizing experiences with the health systems or clinics now seeking their input. Organizers should consider power dynamics when engaging patients, potentially partnering with community organizations and meeting at venues that feel welcoming and familiar to participants such as a neighborhood community center or local school (
). Health systems can also capitalize on existing patient engagement bodies. For example, regional perinatal quality collaborative groups in Michigan integrate community members and parents into quarterly collaboration and planning meetings (
). They use multiple models of engagement, including community members voting on priority areas for the committee, community members sitting on workgroups as full members, and conducting patient focus groups in the development of new programs (H. Joa, Personal Communication July 19, 2021).
Core Concepts
•
Develop structures for meaningful patient participation that are well supported by the institution and implement best practices (Figure 1C).
•
Address power dynamics between patients and the health system by partnering with community groups or holding meetings off the hospital campus.
•
Query patient stakeholders on the scope of interventions, types of bias experienced, and suggestions for improvement.
Outcomes Measures
Implicit bias initiatives are hampered by a lack of robust measures of bias or outcomes, making efficacy challenging to assess (
). Further, evaluations often conflate knowledge retention with changes to attitudes and behaviors, which may not be accurate. In the absence of strong measures, we propose that implicit bias initiatives approach assessment as nested levels: programmatic measures, intermediate outcomes, and end outcomes (Table 2). First, programmatic measures such as participation rates and satisfaction can help to define initial implementation success. Next, intermediate outcomes can be implemented in each domain to rate whether program goals were met. For example, communication initiatives can be measured by patient satisfaction, which has been tied to perceived discrimination, stratified by race (
"We'll get to you when we get to you": Exploring potential contributions of health care staff behaviors to patient perceptions of discrimination and satisfaction.
American Journal of Public Health.2015; 105: 2076-2082
). Although cognitive reframing initiatives lack robust, standardized psychometric measures, one published intervention used tailored assessments to measure varied domains (Table 2) (
). Finally, end-outcomes measurements can assess patient perspectives stratified by race on topics such as perceived support, perceived quality of care, and empowerment to raise concerns with a clinician. Given that data-sharing can lead to improved outcomes, results should be shared at all health system levels, including clinics, clinicians, allied health professionals, and staff (
Special consideration should be given to how implicit bias training is implemented because of its emotional salience. For interventions to be successful, leadership must communicate a commitment to bias reduction and provide resources for program implementation. Buy-in from key stakeholders, including clinicians, staff, and community groups, should be established early in the process. Buy-in can be enhanced by proactively confronting resistance to change and using interval successes to generate momentum (
). In addition to enhanced coordination, interprofessional collaboration should be prioritized because it may lead to stigma-related attitudinal shifts (
). The use of formal implementation models such as “Plan–Do–Check–Act” can help to ensure continuous improvement given the limited durability of interventions studied thus far and the early stage of the literature base (
). Independent obstetrics and midwifery practices can still implement comprehensive programs, even if the scale is more limited, by ensuring that elements of each domain are addressed in some form. Partnering with regional collaboratives can also help to increase access to training.
Conclusions
The decrease of implicit bias is essential for any campaign to combat racism in the pursuit of reduced maternal morbidity and mortality in the United States. Interventions must prioritize patient perspectives and address education, communication, and cognitive reframing. A lack of robust outcomes measures will hamper initial efforts, but this should not dampen our commitment to be better. To enhance this work, national organizations such as ACOG, Society of Maternal Fetal Medicine, and AIM can provide specific, actionable, and accessible resources for each domain. Further, funders can prioritize the piloting and evaluation of initiatives that comprehensively address all domains of implicit bias mitigation.
References
Admon L.K.
Winkelman T.N.A.
Zivin K.
Terplan M.
Mhyre J.M.
Dalton V.K.
Racial and ethnic disparities in the incidence of severe maternal morbidity in the United States, 2012-2015.
in: Mallett R.K. Monteith M.J. Confronting prejudice and discrimination: The science of changing minds and behaviors. Academic Press,
New York2019: 249-274
Detecting implicit racial bias in provider communication behaviors to reduce disparities in healthcare: Challenges, solutions, and future directions for provider communication training.
Patient Education and Counseling.2019; 102: 1738-1743
"We'll get to you when we get to you": Exploring potential contributions of health care staff behaviors to patient perceptions of discrimination and satisfaction.
American Journal of Public Health.2015; 105: 2076-2082
Jonathan Y. Siden, BSW, BA, is a dual MD/MPP candidate at the University of Michigan Medical School and Ford School of Public Policy applying into obstetrics and gynecology. His academic interests include health disparities and social policy.
Biography
Alissa R. Carver, MD, is an Assistant Professor at the University of Michigan Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine. She is the director of the Michigan Obstetrics Safety Team. Her research interests include medical complications of pregnancy.
Biography
Okeoma O. Mmeje, MD, MPH, is an Assistant Professor at the University of Michigan Department of Obstetrics and Gynecology Division of Gynecology. Her research interests include reproductive infectious disease in vulnerable populations, health disparities, and reproductive justice.
Biography
Courtney D. Townsel, MD, MSc, is an Assistant Professor at the University of Michigan Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine. Her research interests include health disparities, substance use disorders in pregnancy, and translational research.
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