Tiffany Green on Rethinking Bias to Achieve Maternal Health Equity

To achieve maternal health equity, decision makers have implemented implicit bias training in perinatal care settings. Implicit bias refers to negative attitudes toward and beliefs about a group and its members that are spontaneously and automatically activated.

In a recent article, “Rethinking Bias to Achieve Maternal Health Equity,” CDE affiliate Tiffany Green argues that legislative and professional efforts mandating implicit bias training are unlikely to produce intended outcomes.

Green and co-authors Jasmine Zapata, Heidi Brown, and Nao Hagiwara argue that treating implicit bias as an individual-level problem decouples bias from social and organizational contexts. Solutions to reduce and eliminate Black-White maternal health disparities must address systemic biases, including stereotyping in medical education and practice and the marginalization of Black physicians.

Green and her colleagues argue for overarching reforms in medical curricula, training, and practice to eliminate racial stereotypes and unscientific views of race. For example, obstetric clinical decision making relies on race and ethnicity to calculate a patient’s probability of successful vaginal birth after cesarean (VBAC). For two identical patients—for instance, a 30-year-old woman, 5’6” tall, 200 pounds, with a prior cesarean delivery for breech presentation—the predicted probability of VBAC is 66% if the patient is White and 50% if the patient is Black, according to the calculator. Because cesarean deliveries carry higher risk for avoidable maternal morbidity, relying on a race-based calculator for clinical practice will exacerbate racial disparities in health.

Institutionally sanctioned racial stereotyping harms Black maternal health and marginalizes Black physicians—a key group in the fight for health equity. Racial stereotyping in medical settings goes unchallenged without the perspectives of Black students and physicians, and the underrepresentation of Black physicians in leadership roles leaves health organizations without novel perspectives on how to restructure health care to improve racial and ethnic disparities in maternal health.

To improve the recruitment and retention of Black medical students and doctors, Green and her colleagues call on institutions to proactively create programs and support systems for aspiring Black physicians. Additionally, the authors encourage medical schools and residency programs to adopt holistic admissions policies that take into consideration applicants’ background and experiences with discrimination and poverty. They also note that institutions must adopt zero tolerance policies for racial discrimination and provide concrete financial and other resources to recruit and retain Black faculty.

Finally, Green and her colleagues assert that changes in standardized medical protocols to improve outcomes (e.g., quality improvement initiatives to reduce maternal morbidity) must be pilot tested before widespread implementation. This will help ensure they do not unintentionally worsen racial inequalities in maternal health. Additionally, patients of all backgrounds must receive guideline-based care that is developed from clinical studies in which Black women are well-represented.

Together, these recommendations could improve maternal health disparities and address the systematic forms of racism in health care.