Why It Matters
Can anti-bias training help to reduce inequities in health care? A range of stakeholders share their recommendations for how implicit bias training could improve Black maternity outcomes.
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Across the US, states and health care systems have been considering — and sometimes enacting — requirements that health care workers participate in anti-bias or “implicit bias” training. Our colleagues discovered that between 2019 and mid-2022, 25 states and Washington, DC, introduced legislation addressing implicit bias training for health care providers. Six enacted it. California, our home state, passed such a requirement into law in late 2019 as part of the “Dignity in Pregnancy and Childbirth Act” (2019 Senate Bill 464 or “SB 464”).
Many patients, advocates, health care workers, and researchers harbor some skepticism about whether anti-bias training can help to reduce inequities in patient outcomes — particularly maternal health outcomes, which are powerfully shaped by structural factors, such as maternity care “deserts” and minoritized patients’ greater likelihood of delivering in lower-performing hospitals.
However, interpersonal factors such as discrimination and disrespectful care meaningfully diminish maternity care patient experience and safety as well. This was echoed by Black mothers in our recent study who, reflecting on past care experiences and what they wanted in the future, desired to be treated “like we are people . . .Treated like my voice matters and [health care providers are] actually listening.” Another new mother said she wanted her doctor “to treat me like a human being.” This wish came up again and again in our focus groups.
Acknowledging that antibias requirements represent an historic opportunity to potentially address minoritized patients’ wish for more respectful and equitable maternity care, we sought to understand what effective implicit bias training (IBT) looked like. As we explain elsewhere, no published scholarship showed what IBT approaches produced improvements in maternal health outcomes or changes to clinician practice. We knew it would be important to go directly to key stakeholders — the clinicians who would take the training and the patients meant to benefit — to ask these questions.
We (principal investigator, Sarah Garrett, and co-investigator, Linda Jones) along with co-investigator Sarah Hooper, JD (UC Law San Francisco), convened a team for this work, bringing together community collaborators, legal scholars, and social science researchers to create the MEND Study: Multi-Stakeholder Engagement with State Policies to Advance Antiracism in Maternal Health. Referencing the goals of California’s SB 464, we studied stakeholders’ views on the challenges and recommendations for IBT that could improve care and clinical outcomes for Black women and birthing people.
We conducted focus groups and surveys with Black women who had a hospital birth (n=20) and in-depth interviews and surveys with multidisciplinary perinatal clinicians who worked in a community or safety-net hospital (n=20; e.g., CNMs, RNs, MDs). All participants were based in the San Francisco Bay Area.
The central findings of the MEND study were published recently in Health Equity. Patients and clinicians alike had concerns about whether clinician IBT could produce better care and improved clinical outcomes. As we outline in the paper, they identified challenges related to state law, training, health care facilities, and the clinician learners. Importantly, many participants expressed the view that IBT would not meaningfully improve outcomes without accompanying system-level interventions, such as increasing racial/ethnic workforce diversity and enhancing supports for pregnant, parenting, and postpartum individuals.
However, respondents supported IBT’s use and identified many ways to maximize its effectiveness. Recommendations from both our patient and clinician respondents overlapped substantially:
- Enhance the scope and nature of state law. Respondents recommended that lawmakers create clear and effective enforcement mechanisms; expand the scope, intensity, and funding of IBT; mandate IBT for the entire maternity health care workforce; and create accountability for improved patient care and outcomes. The latter was a particularly high priority for patient respondents.
- Broaden IBT content and format. Respondents recommended that curriculum designers enrich training content by, for example, including data about the trainee’s facility (e.g., outcome inequities); real stories from patients about their care experiences; and information about the history of racism in US. They strongly recommended that those implementing IBT employ an interactive training format and support trainees’ ongoing and applied antibias skills-building.
- Support sincere provider and staff engagement. Respondents expressed that those taking the IBT should engage training seriously and with an open mind; recognize their own biases; and participate in supplemental training if they received ongoing complaints of biased behavior.
- Foster a health care facility culture and environment conducive to antibias work. Respondents recommended that health care system, department, and unit leaders foster safe spaces for ongoing learning and discussion; ease logistics (e.g., time and schedule constraints) to facilitate trainees’ focused participation; enhance IBT legitimacy by engaging respected facility champions and trainers. They urged leaders and managers to create accountability systems to support IBT participation and reductions in biased care; and to implement complementary interventions (e.g., health care workforce diversification) that could synergistically strengthen health equity efforts in the facility.
We outline action steps based on these recommendations in a facility IBT planning guide.
In a policy report led by MEND’s legal collaborators, we additionally present a socio-legal analysis of California’s SB 464 and actionable policy recommendations. The report identifies key barriers and gaps that threaten the law’s meaningful implementation and call for further action to ensure that the law is implemented in a manner consistent with its stated intent:
“Primarily, we recommend the creation of a state task force to conduct initial coordination and oversight of implementation efforts. This body would be tasked with gathering information and data to provide recommendations to the state regarding four aspects of IBT implementation: 1) evidence-based practices for design and implementation of IBT curriculum and related quality improvement efforts; 2) initiatives to foster transparency around IBT implementation and outcomes; 3) strategies to incentivize and enforce IBT requirements; and 4) designation of a state agency for long-term oversight of implementation and enforcement of the goals of SB 464.”
These steps complement and support recommendations that the California Department of Justice (DOJ) recently published. Discovering modest rates of compliance by reporting facilities — two and a half years after the law took effect, only 17 percent had trained all covered providers, 76 percent had trained a subset — the DOJ called for changes to improve IBT enforcement, accountability, and transparency. (Illustrating the power of accountability, nearly one-third of hospitals did not initiate training until the DOJ inquired in Fall 2021 about training compliance 20 months after the requirement took effect.) The DOJ additionally called for the ongoing integration of evidence to improve antibias training. MEND findings represent home grown community-defined and practice-based additions to the IBT evidence base.
Importantly, conversations our team has had with researchers, health care administrators, birth equity advocates, patients, and health care workers suggest that both the IBT recommendations and the policy recommendations that MEND generated can be useful outside of California as well. Many of the insights are relevant to health care system requirements and legislation under consideration in other states. Preliminary research we conducted last fall additionally supports this possibility.
Implicit bias training requirements represent one of many multi-level efforts needed to improve the care and outcomes for Black women, birthing people, and other historically minoritized populations. We hope our stakeholder-grounded work contributes to ways health care leaders, advocates, state agencies, and legislators can work toward these goals.
Sarah B. Garrett, PhD is faculty at the Phillip R. Lee Institute for Health Policy Studies at the University of California, San Francisco. Linda Jones is a Birth and Postpartum Doula with Black Women Birthing Justice.
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