Will Mandatory “Unconscious Bias” Training For California Health Workers Actually Reduce Patient Deaths?

Tuesday, May 7, 2019
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California lawmakers are introducing a set of bills that would require state healthcare workers to undergo “implicit bias and racism” training every two years. The reason? Maternal mortality rates among black women are about three times as high as for non-Hispanic white women, Hispanic women, and Asian women. These lawmakers believe that implicit bias against black women by doctors, nurses, and other health-care workers is the key reason why black maternal mortality is high and that mandatory diversity training will reduce unconscious racism, resulting in far fewer black women dying during childbirth.

So just what is “implicit bias”?  It goes something like this. You may think that you treat all people fairly and equally, irrespective of their sex, race, religion, sexual preference, and anything else that might come to mind, but those who make their living in the world of implicit bias will tell you that you are wrong about your egalitarian nature and you just don’t know it. After all, this is your subconscious. They will also tell you that your unconscious biases significantly affect your decision making and the well-being of those whom you unknowingly discriminate against.

But is unconscious racism on the part of obstetricians, nurses, physician assistants, and other healthcare workers who interact with expecting moms the main reason why black maternal mortality is so high? You would expect that there must be a compelling logical explanation for such an assertion, as well as strong supporting evidence for lawmakers to pursue such legislation.

As is often the case in the world of California law making, this logical protocol for developing legislation is not applied. There is in fact very little evidence supporting the claim that unconscious bias is causing high black maternal mortality; there is no chain of logic that would reasonably lead you to conclude that the proposed legislation will be useful; and there are alternative policies that would likely be much more effective at improving women’s health outcomes at a lower cost.

There is virtually no statistical evidence that racism and bias are the main factors causing high black maternal mortality. In fact, the statistics suggest that racism is not playing a significant role. If it were, then Hispanic women should also be suffering abnormally higher maternal mortality, just as black women do, because Hispanics report racism about as frequently as blacks.  But in sharp contrast, Hispanic women experience very low maternal mortality rates, even lower than for non-Hispanic white women. If racism is the cause of high maternal mortality, then why are the rates for Hispanic women so much lower than for black women?

Moreover, if bias and racism were the main cause, then we would should observe that the states with the most racism and conflict would tend to have the highest prevalence of black maternal mortality. But this does not appear to be the case. Only two of the 10 most “hateful” states, as identified by the Southern Law and Poverty Center, have black maternal mortality rates that are above the national average. Similarly, New Jersey, which is regarded as one of the most progressive states in the country in terms of making racial progress, has the highest black maternal mortality rate in the country.

Recent studies of maternal mortality provide little, if any, evidence that bias plays a role. Studies do show that black women have higher maternal mortality rates, but they also show that out-of-wedlock births, unintended pregnancies, and less prenatal care are also associated with a higher risk of maternal mortality

However, since black women have higher rates of both out-of-wedlock births and unintended pregnancies, and since they also receive less prenatal care, then the high black maternal mortality statistics may simply reflect these risk factors that disproportionately affect black women. Bias may have relatively little to do with maternal mortality.

It is therefore both puzzling and deeply concerning that lawmakers are ignoring reasonable potential explanations for these maternal mortality statistics and instead are jumping to the conclusion that bias is the main reason behind maternal deaths.

Now, it may be the case that social factors may indirectly matter for understanding these statistics. For example, better communication between healthcare workers and expecting moms may improve maternal health.  But testing healthcare workers for implicit bias and requiring diversity training based on implicit bias test results will almost certainly be ineffective.

One reason is that the scientific claims for implicit bias research are woefully lacking. Implicit bias test results can vary enormously across individuals, sometimes showing significant biases and at other times showing none. After initially claiming that implicit bias is not only a sizable cause of black disadvantage, but that “it plausibly plays a greater role than does explicit bias, the most comprehensive study reverses this conclusion. This study, co-authored by one of the test’s original developers, found that, after analyzing hundreds of implicit bias studies involving 81,000 people, “there is very little evidence that changes in implicit bias have anything to do with changes in a person’s behavior.”   

Moreover, forcing individuals to be tested for implicit bias and then requiring them to receive diversity training can actually backfire if they are not open to the idea or if they do not believe the results.

It is tragic that black women suffer such high maternal mortality rates. Since many pregnancy-related deaths are preventable, this is an important public-policy question in which getting the policy right can make a big difference.

But the state legislature’s conclusion to identify and remediate unconscious bias among healthcare workers has virtually no logical or scientific support. There is no doubt that diversity trainers would benefit from this required training, but I doubt that this would save the lives of many mothers.

There are much better ways to address this issue. There is no doubt among healthcare workers that adequate prenatal care can make a big difference in terms of maternal and fetal health. Just imagine how much progress could be made if the resources that would be spent on identifying implicit bias and re-educating could be invested to increase prenatal care.