Reducing Implicit Bias, Raising Quality of Care May Reduce High Maternal Mortality Rates for Black Women

In the United States, Black women are three to four times more likely to die of a pregnancy-related death[1] (maternal mortality) than white women, and recent studies suggest that up to half of all maternal deaths may be preventable. Black women are also more likely to experience severe birth complications, known as maternal morbidity. Medical providers’ implicit biases and lower-quality care at hospitals that serve Black women are two factors that contribute to these disparities; addressing these factors is critical to reducing Black women’s rates of maternal mortality and birth complications.

Research and media accounts show that implicit bias may negatively affect Black patients’ medical care. One study found that white medical students who held racial biases rated Black patients’ pain lower than that of white patients, and their treatment recommendations for Black patients were less accurate. Another study, done in New York City, found that Black, college-educated women who gave birth in local hospitals were more likely to suffer life-threatening complications than non-Black women with less than a high school education.

Media accounts are also drawing attention to Black women’s pregnancy-related medical care. In more than 200 stories collected by ProPublica and National Public Radio, many Black mothers recounted feeling devalued and disrespected by medical providers. A young, pregnant Black woman in Florida complained of breathing problems. Her lungs were filling with fluid, but doctors assumed her breathing problems were caused by obesity. An epidemiologist died, shortly after giving birth, from high blood pressure complications after she complained of symptoms and doctors ignored her.

Eliminating racial disparities in maternal mortality rates may also require improving the quality of care that Black women receive. Research findings show that most deliveries to Black mothers occur in a concentrated set of hospitals that have higher rates of severe maternal morbidity. (Both Black and white women who delivered in these hospitals had a higher risk of severe maternal morbidity.) Adjusting for hospital characteristics had little effect on this finding, which may suggest that hospitals serving mostly Black women provide a lower quality of care than those that serve a smaller number of Black women. Targeting quality improvement efforts at these hospitals may have benefits for other women receiving care and may reduce maternal morbidity for many Black women.

The Preventing Maternal Deaths Act, signed in 2018, funds states to create committees to examine maternal mortality and morbidity rates. Medical facilities can also take action. To reduce maternal mortality disparities and birth-related complications experienced by Black women, hospitals and other medical facilities can address implicit biases and improve their quality of care:

• Educate clinicians and staff on cultural competency and implicit bias. The Council on Patient Safety in Women’s Health Care produced an educational tool on racial disparities and implicit bias that facilitates timely, tailored responses to reports of inequity. This tool provides a framework to help providers reduce racial disparities in healthcare quality.
• Ensure that Black women have access to clinical and social support interventions that can reduce preventable complications. For example, early warning systems are sets of specific clinical symptoms and vital sign thresholds that trigger an urgent patient evaluation. One such system, Maternal Early Warning Triggers, was piloted and found to lower maternal morbidity rates. Doulas, who support mothers in their interactions with the health care system, may also play a crucial role in reducing complications. An analysis in a prenatal health program found that doula-assisted mothers were nearly half as likely to experience birth complications, compared to mothers who did not have a doula.
• Use disaggregated data to monitor maternal morbidity and mortality rates for Black women. Breaking apart data by race and ethnicity may help hospitals identify gaps in care and address racial disparities in maternal mortality and morbidity rates. In fact, hospitals have used disparities dashboards with disaggregated data to pinpoint and address disparities in other health outcomes. Reporting data on maternal mortality and morbidity rates may help facilities further identify gaps and implement interventions to address disparities.

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[1] The Centers for Disease Control and Prevention defines a pregnancy-related death as “the death of a woman while pregnant or within 1 year of the end of a pregnancy—regardless of the outcome, duration or site of the pregnancy—from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”