Black Mamas

Implicit Bias: The Outcomes Tell Us What Black Mothers Already Know

April 11, 2022

April 11-17 is Black Maternal Health Week, which shines a spotlight on the disproportionately poor maternal health care and health outcomes Black mothers experience.  While these outcomes are the proof, it’s what happens in medical practice and in individual patient-provider interactions that drives these outcomes.

Inequity in maternal health outcomes is not new. Not only does the U.S. continue to have unacceptably high rates of maternal mortality and morbidity, but due to structural racism, Black women are dying and suffering from poor maternal outcomes at significantly higher rates (up to three to four times) than non-Hispanic White women. Moreover, survey data confirm that Black women are also more likely to report being treated unfairly during their stay in the hospital because of their race or ethnicity.

Remember Serena Williams’ story? The harrowing tale of her experience giving birth and the fight to get providers to believe her about the complications she was experiencing after – several small blood clots had settled in her lungs – put an iconic and famous face to the plight of Black mothers. It raised a frightening question: “If Serena Williams can’t get proper care, what hope is there for the average Black woman?”

For the hope of Black women receiving care that is free of bias, discrimination, and racism to become reality, the health care industry needs to look hard at how racial and implicit biases influence care delivery and outcomes – and then design and implement solutions.

Racial and implicit bias in care is not new either (and has become institutionalized in our health care system), but with the health equity awakening sweeping the country, a long-awaited spotlight is shining on what has been the lived truth for far too many Americans.

Microaggressions, defined as “brief, commonplace, daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults toward people of color” are one form of bias. While many instances of microaggressions are quick in passing, the negative effects on how they make people feel are lasting.

As an Asian American there are firsthand examples I can share. A few years ago, I was having a friendly chat with my PCP about favorite foods, and he asked if I liked tofu. On an urgent care visit, the doctor asked me where I was from in a tone of voice that suggested I wasn’t a local. The first instance relied on stereotypes of Asian people and culture. The second implied that, since I am Asian, I must have grown up “somewhere else.” Asking me versus a White person where I am from takes on an entirely different meaning. Even if these providers committed these microaggressions unwittingly, they negatively affected my relationship with and regard for them.

Microaggressions make the people who they are directed at feel uncomfortable, hurt, and different. They undermine a patient’s trust of providers and create barriers or hesitations to seeking future care. According to a 2015 study on the influence of racial bias on health care outcomes “…results also showed that implicit bias was significantly related to patient–provider interactions, treatment decisions, treatment adherence, and patient health outcomes.” Another study found that “Persons who thought that they would have received better treatment if they were of a different race were significantly less likely to receive optimal chronic disease screening and more likely to not follow the doctor’s advice or put off care.” Bringing this back to Black maternal health, one can see how regular microaggressions can have a very real impact on the care a Black expectant mother receives over the course of nine months.

Implicit bias shows up in many tangible ways as well – through direct action and behaviors. A recent studyanalyzed electronic health records from an urban academic medical center to determine whether providers’ use of negative patient descriptors (such as “resistant” or “noncompliant”) varied by patient race or ethnicity. The study found that “compared with White patients, Black patients had 2.54 times the odds of having at least one negative descriptor in the history and physical notes.” In addition to creating and perpetuating racial bias in the medical record itself, research shows that providers reading notes containing stigmatizing language is “associated with more negative attitudes towards the patient. Furthermore, reading the stigmatizing language note was associated with less aggressive management of the patient’s pain.”

Another way which implicit bias harms Black Americans and other people of color is when that bias manifests as false, racially-driven medical beliefs. In an AAMC editorial, the author reveals myths – believed by up to 40% of medical students and residents – such as “Black people’s nerve endings are less sensitive than White people’s” and  “Black people’s skin is thicker than White people’s.” These beliefs are also related to the prevailing myth of biological race, and the racism that stems from and supports it. They also result in unequal and inequitable pain management of Black versus White patients. When it comes to Black mothers, this becomes especially concerning given the role that pain management plays before, during, and after a delivery.

Indeed, uprooting and correcting these deep-rooted biases will be challenging. Employers and other health care purchasers looking to take steps in the right direction can:

  • Better educate themselves on the issues outlined above.
  • Better understand how these issues play out for their organizations by working with employees of color and with community organizations.Work with health plans to diversify the provider pipeline and implement anti-bias training for network providers
  • Hire Chief Equity Officers (assuming a real scope of reach and the actual power to create change).
  • Track health care quality and other performance metrics that identify disparities in care and outcomes across your population. More information on these available here.

They can also look to their peers.

During CPR’s March 31, 2020 webinar, Sara Rothstein, former director of the 32BJ Health Fund, provided an overview of the Fund’s new program to improve maternity care among its 200,000 plan participants. The Health Fund calls it the High-Value Maternity Care Network.

The program uses patient-reported measures to center the needs of patients who may be more vulnerable to poor quality of care. To do this, the 32BJ Health Fund created an accountability structure, asking patients to respond to the following questions: “Was I treated with dignity and respect during my labor and delivery experience? Were my concerns heard?” Participating health systems made commitments to address instances in which patients report negative experiences in addition to reporting health outcomes by race and ethnicity. The use of this accountability structure puts the 32BJ Health Fund’s High-Value Maternity Network on the cutting edge of the health equity movement.

This April and beyond, the health care industry needs to focus on addressing implicit bias, discrimination, and racism in health care delivery in order to transform maternity care into an equitable service for all women.


CPR’s Assistant Director of Projects and Research, Lea Tessitore, MBA, MSB, wrote this blog. As a bioethicist, Lea uses her unique perspective and formal principles of health care ethics to inform CPR’s work.

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