Provider implicit and explicit bias in person-centered maternity care: a cross-sectional study with maternity providers in Northern Ghana

Abstract

Background Person-centered maternity care (PCMC) has become a priority in the global health discourse on the quality of care due to the high prevalence of disrespectful and lack of responsive care during facility-based childbirth. Although PCMC is generally sub-optimal, there are significant disparities. On average, women of low socioeconomic status (SES) tend to receive poorer PCMC than women of higher SES. Yet few studies have explored factors underlying these inequities. In this study, we examined provider implicit and explicit biases that could lead to inequities PCMC based on SES. Methods Data are from a cross-sectional survey with 150 providers recruited from 19 health facilities in the Upper East region of Ghana from October 2020 to January 2021. Explicit SES bias was assessed using situationally-specific vignettes (low SES and high SES characteristics) on providers’ perceptions of women’s expectations, attitudes, and behaviors. Implicit SES bias was assessed using an Implicit Association Test (IAT) that measures associations between women’s SES characteristics and providers’ perceptions of women as ‘difficult’ or ‘good’. Analysis included descriptive statistics, mixed-model ANOVA, and bivariate and multivariate linear regression. Results The average explicit bias score was 18.1 out of 28 (SD = 3.60) for the low SES woman vignette and 16.9 out of 28 (SD = 3.15) for the high SES woman vignette (p < 0.001), suggesting stronger explicit bias towards the lower SES woman. These biases manifested in higher agreement to statements such as the low SES woman in the vignette is not likely to expect providers to introduce themselves and is not likely to understand explanations. The average IAT score was 0.80 (SD = 0.34), indicating a significant bias in associating positive characteristics with high SES women and negative characteristics with low SES women. Providers with higher education and years of experience had significantly lower explicit bias scores than those with lower education and experience. Providers in private facilities had higher IAT scores than those in government hospitals. Conclusions The findings provide evidence of both implicit and explicit SES bias among maternity providers. These biases need to be addressed in interventions to achieve equity in PCMC and to improve PCMC for all women.

Mixed methods evaluation of the Caring for Providers to Improve Patient Experience intervention

“…This research also highlights inequities in PCMC with the most vulnerable groups having the worst experiences 6–10 . Two key drivers of poor PCMC and inequities in PCMC are provider burnout and bias 11–17 …”

“…Second, given the role of bias in health care inequities and the dearth of evidence on effective ways to address it, 15,17,33 CPIPE demonstrates efforts to promote health equity through bias awareness and mitigation. Third, there is a major gap in theory and evidence-based interventions to promote responsive, compassionate, and respectful maternity care.…”

“…Two situationally specific vignettes assessing providers' perceptions of women's PCMC expectations and behaviors based on socioeconomic status (SES). 15,17 One vignette describes a woman with low SES and the other vignette describes a woman with high SES; vignettes were read in counter-balanced orders to providers and followed by eight questions assessing providers' perceptions of the woman's expectations for introductions, consenting, companionship, potential to cooperate, understand explanations, and exaggerate pain; and provider behavior needed to convey seriousness and gain patient cooperation. The vignettes and questions were informed by measurement of explicit bias in prior literature 65,66 and prior research in this setting.…”

“…[38][39][40] Studies in SSA have highlighted the role of provider bias in PCMC, demonstrating differential care provision based on women's appearances, perceived compliance, aptitude, and self-advocacy. [13][14][15]17 Patient experience is intrinsically linked to provider experience. Provider stress and burnout contribute to negative patient experiences, [11][12][13]16 while provider bias contributes to inequities in PCMC.…”

“…[6][7][8][9][10] Two key drivers of poor PCMC and inequities in PCMC are provider burnout and bias. [11][12][13][14][15][16][17] Burnout, a state of physical, mental, and emotional exhaustion, is an important predictor of both poor patient and provider experiences. 18,19 A key symptom of burnout, depersonalization, manifests as negativism, cynicism, and poor attitudes towards patients, leading to poor patient experiences.…”