More evidence is needed to determine the impact of healthcare professional implicit bias training on maternal health outcomes.
This assessment was made possible through support from Elevance Health. HealthBegins retains full editorial independence, and the content herein reflects its sole views and conclusions.
The findings below synthesize the results of the studies on healthcare professional implicit bias training across three domains of measurement:
Maternal Health Care
Maternal health encompasses a person’s health during pregnancy, birth, and postpartum[1]. Out of 3.7 million births in the United States (U.S.) in 2021, 41% were covered by Medicaid[2],[3]. Medicaid covered over half of births among Black and Hispanic individuals[4]. Medicaid also covers a large portion of individuals who are under age 25[5].
Adequate prenatal and postpartum care is integral to maternal health. In 2022, 74.9% of individuals who are birthing received early and adequate prenatal care while the percentage of birthing people receiving no prenatal care increased to 2.3% in 2023[6],[7]. Postpartum visit rates vary from 24.9% to 96.5%[8]. In addition to varying postpartum visit rates, the content and quality of care provided vary widely based on insurance, rural versus urban setting, and race/ethnicity[9]. Additionally, between 12%-17% of the gender-diverse individuals assigned female at birth have been pregnant at least once[10],[11].
The U.S. has the highest rate of maternal mortality (death within 42 days from the end of pregnancy from any cause related to the pregnancy or its management), when compared to other high-income countries[12],[13]. In 2022, the maternal mortality rate was 22.3 deaths per 100,000 live births[14]. Between 2017-2019, 80% of pregnancy-related deaths were deemed preventable[15]. The maternal mortality rate for non-Hispanic Black women is 2.6 times the rate for non-Hispanic White women[16]. The top three causes of pregnancy-related deaths for Hispanic/Latino and White birthing people are mental health conditions, hemorrhage, and a tie between cardiac/coronary conditions and infection. For Black women, the top three causes of pregnancy-related deaths are cardiac/coronary conditions, cardiomyopathy, and thrombotic embolism[17]. Overall, mental health conditions are a leading underlying cause of all pregnancy-related deaths, accounting for 23% of such deaths (e.g., deaths by suicide and overdose/poisoning related to substance use disorder)[18]. Death by suicide accounts for about 20% of postpartum deaths[19].
Pregnant and postpartum individuals also experience a 16% increase in the incidence of homicide compared to those who are not pregnant or postpartum. Homicide is the leading cause of all-cause maternal mortality during pregnancy or within 42 days of the end of pregnancy, accounting for more than two times the other leading causes of death during this period[20].
Maternal morbidity includes any health problems that cause death from pregnancy, both short- and long-term, including cardiovascular disease, infection, bleeding, high blood pressure, and blood clots[21]. One estimate found that roughly 29% of pregnancies include some maternal complication or morbidity, with about 11% of pregnancies including a life-threatening complication[22]. Pregnant Black individuals experience higher rates of maternal morbidity caused by eclampsia/preeclampsia and venous thromboembolism or pulmonary embolism, while pregnant Asian/Pacific Islander individuals experience higher rates of severe postpartum hemorrhage[23].
Maternal Health and Social Needs
Pregnancy and postpartum can exacerbate health-related social needs and compound their negative effects. A pregnant individual’s access to screening for medical risk factors is affected by social and structural drivers of health, such as access to basic needs like transportation and childcare. However, even after such risks are identified, people who are pregnant may not be able to access resources to address those needs due to the same social and structural drivers of health that lead to poor health in the first place[24].
While emphasis is placed on the pregnancy and birth stages of maternal health, physical and mental health concerns remain significant in parenthood and are exacerbated by social needs. According to 2023 data, 48% of parents say that their stress is overwhelming most days compared to 26% among other adults[25]. Parental stressors include financial strain, economic instability, poverty, time demands, children’s health/safety concerns, parental isolation and loneliness, technology and social media, cultural pressures, and worry about children’s futures. Another parental stressor is the cost of childcare. The cost of childcare is inaccessible for many families as the cost is equivalent to 8%-19.3% of the median family income per year for each child in paid care[26].
Implicit bias, “also known as implicit prejudice or implicit attitude, is a negative attitude, of which one is not consciously aware, against a specific social group”[27]. Implicit bias training aims to help healthcare professionals recognize their inherent biases, understand how they may impact clinical care, and develop strategies to mitigate their effects from developing into potentially harmful patient outcomes. A 2018 systematic review found training on implicit bias can have meaningful and statistically significant effects on practice and communication across disciplines and clinical areas[28]. By fostering awareness and equipping healthcare professionals with tools to ensure equitable care, implicit bias training seeks to bridge gaps in maternal health outcomes, enhance patient-provider trust, and improve overall healthcare quality[29].
Implementing implicit bias training has been identified as a step toward addressing inequities and promoting health equity within maternal healthcare. While implicit bias training alone may not eliminate health disparities, the literature suggests that it is a critical component in a multifaceted approach to achieving more equitable healthcare. Feedback from patients with maternal health needs suggests that the entire care team be included and lived experiences be used as training tools. More high-quality evidence on long-term impacts is needed. Still, existing research supports the role of implicit bias training in promoting awareness, reducing bias in care delivery, and laying the foundation for systemic change and quality improvement.
Healthcare provider training on implicit bias focuses on addressing subconscious biases that healthcare professionals may have, which can influence their clinical decision-making and patient interactions. These unconscious biases or stereotypes are often driven by life experiences and filters. Healthcare professional licensing regulations are increasingly requiring implicit bias training because of its importance and impact on multiple areas of health, including maternal health[34]. Research has shown that implicit bias contributes to disparities in maternal health outcomes, especially among marginalized groups[35]. Black women and other women of color, for instance, face disproportionately higher rates of maternal morbidity and mortality compared to their White counterparts, even when socioeconomic factors are accounted for[36].
Neonatal intensive care unit (NICU) nurses in a level IV NICU at Cedars-Sinai Medical Center (CSMC).
NICU nurses in 60-minute small-group workshops discussing health inequities and implicit biases. The workshop leaders were a neonatologist and the NICU Clinical Nurse Specialist. Each session started with an introduction to health disparities and implicit bias, which included a review of recent literature and feedback gathered from a cohort of Black mothers' past experiences in the CSMC NICU. Role-playing simulations were used to demonstrate examples of implicit bias.
Pre-post surveys. Before beginning each workshop, the participants completed an electronic survey requesting demographic data and their self-reported understanding of health disparities. All questions were in Likert scale format. After each workshop, the participants completed another survey that summarized their experience. A six-month follow-up survey was used to inquire how the participants’ experience had influenced their ongoing considerations of health inequities and about the longstanding value of the workshop. A total of 95 participants completed the in-person workshops, with the majority identifying as ‘female’ between the ages of 20 and 40.
Social: Post-survey results revealed that 99% believed the workshop to be a valuable learning experience, with a preference (94%) for in-person learning compared to virtual options. 97% identified increased mindfulness of the patient experience based on race and socioeconomic background, with an overwhelming majority of participants interested in continued education in health inequities. The six-month follow-up survey showed that 99% of respondents felt there continued to be value in discussing the impacts of race on their work in the NICU.
Medical trainees.
The intervention group viewed a photo documentary and attended a forum where Latino adolescents presented photographs and themes generated from a Photovoice project—the intervention aimed to reduce negative bias towards Latinos among medical trainees.
Pilot sequential cohort, post-test design with 69 medical trainees.
Social: Compared to the control group, participants in the intervention group showed greater ethnocultural empathy, healthcare empathy, and patient-centeredness. However, there was no difference in implicit anti-Latino bias between the groups. However, in a subset analysis, White participants in the intervention group demonstrated a significantly decreased level of implicit bias in being pleasant between study groups. The study also found a dose-response indicating that participants involved in more parts of the intervention showed more change on all measures.
Medical students.
An implicit bias workshop.
The Implicit Association Test (IAT) was used to measure implicit bias in pre- and one-year post-workshop attendance. 272 students participated in the workshop.
Social: The authors reported statistically significant improvements in implicit bias immediately after the workshop, but improvements did not persist at a one-year post-workshop survey.
Nurses employed in a women’s services unit in a midwestern urban hospital.
Educational modules on implicit bias in perinatal care were assigned to participants.
A post-education IAT and survey were administered. An analysis of participants' survey results was performed. The primary outcome of interest was the level of implicit bias awareness among staff nurses as determined by pre- and post-training surveys. A total of 31 pre-education surveys and 28 post-education surveys were returned.
Social: All results indicated statistical significance on the questions related to the engagement behaviors of nurse participants. No significant difference was found on the other items. Participants indicated a mean of 4.37 (SD=0.74) on the post-education question, “I feel more aware of implicit bias and its effects on perinatal outcomes,” indicating a strong positive effect.
Registered nurses in labor and delivery and postpartum units at two community hospitals, a 239-bed community hospital in southern New Jersey and a 665-bed hospital in Pennsylvania, both part of the same health system.
An hour-long Zoom session of voluntary implicit bias training coordinated by the health system’s Diversity, Equity, Inclusion and Community Department.
The pre- and post-training results of the free, online Implicit Association Test were compared. A two-question post-training survey assessed what was learned and how it will be used in practice. 13 White female participants with a mean age of 49.83 years completed the study.
Social: Results of the Implicit Association Test showed that an educational session on implicit bias did not elicit a statistically significant change in participants’ association between race and bias concepts (p = 0.891).
80 staff members at two clinical sites in Cleveland, Ohio.
Breaking Through Bias, a training program, provides healthcare professionals with skills to recognize and remedy implicit bias in maternity care settings. It includes an introduction to implicit bias, a historical overview of structural racism in the United States, strategies to mitigate racial bias in maternity care, and strategies to build a culture of equity.
A mixed-methods evaluation was used to capture changes in knowledge and awareness of bias, as well as apply strategies to reduce biased behavior by conducting pre- and post-training surveys immediately after training and interviews at three- and six-months post-training. Univariate and bivariate analyses were conducted for the surveys while interviews were recorded, transcribed, and analyzed for themes.
Social: 50 of 80 (62.5%) trainees who engaged in the evaluation passed the pretraining knowledge questions, and 67 (83.8%) passed the post-training knowledge questions. Of the 80 participants, 75 (93.8%) were women. Interviewees (n = 11) said that low staff-to-patient ratios, lack of racial and ethnic diversity in leadership, inadequate training on implicit bias, and lack of institutional consequences for poor behavior exacerbated bias in maternity care. Interviewees reported having heightened awareness of bias and feeling more empowered after the training to advocate for themselves and patients to prevent and mitigate bias in the hospital.
First-year medical students.
Active learning workshops. Participants engaged in two workshops that covered the psychology of intergroup bias, the role of implicit bias in the delivery of care, and activities for learning six strategies for controlling the implicit stereotyping of individuals.
Pre-post measures on the Implicit Association Test (IAT).
Social: Before the workshops, the level of implicit bias toward Hispanics was significant for the White (majority group) and Asian-American and foreign-born students from East Asia and Southeast Asia (non-identified minority group), but not for the Hispanic, Black, and American Indian (identified minority group) students. After the workshops, Hispanic, Black, and American Indian (identified minority) students again showed no bias, and implicit stereotyping was significantly lower for the White (majority) group students but not for the Asian-American and foreign-born students from East Asia and Southeast Asia (non-identified minority). Workshops may have been effective in the short-term for majority group and identified minority group students, but more cultural tailoring of the materials and activities may be necessary to address implicit bias among some minority group medical students.
Obstetrics and gynecological residents in a large urban hospital in Texas.
Mind Your Mama! was an educational intervention online. It consisted of four Zoom workshops, each lasting three hours, held between September and November 2020.
The Black-White Implicit Association Test and the Motivation to Control Prejudice Reactions Scale were administered pre-, immediately post-, and three months post-intervention. Changes in racial implicit biases and motivation to manage bias were evaluated.
Social: The workshop helped 86.4% of participants increase their awareness of personal implicit bias, 86.6% of participants to make connections between racism and healthcare disparities, and increased motivation in 85.7% of participants to provide care based on human rights and reproductive justice. The workshop increased motivation to be antiracist in 90.9% of participants at the three-month follow-up, and 100% of participants incorporated one or more antiracist strategies learned in the workshop.
Not applicable.
Interventions designed to reduce implicit bias.
A systematic review of studies from 2005 to 2015 measuring the effects of interventions designed to reduce implicit bias using the Implicit Association Test (IAT). 30 studies covering 47 different implicit bias interventions were included in the review.
Social: The most effective categories addressed intentional strategies to overcome biases, exposure to counter-stereotypical exemplars, identifying the self with the outgroup, evaluative conditioning, and inducing emotion. Many interventions have no effect or may even increase biases. Some techniques, such as engaging with others’ perspectives, appear unfruitful, at least in short-term implicit bias reduction, while other techniques, such as exposure to counter-stereotypical exemplars, are more promising. Robust data is lacking for many of these interventions.
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[11] The language used in this assessment reflects what is used in the literature (e.g., “women”). While it may accurately reflect the study data, it may not be inclusive of or relevant to the experience of gender-diverse individuals.
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