Skip to content
A Multiethnic Group Of Young Friends Enjoy Good Food And Conversation Together On A Terrace Outside On A Summer Evening. The Focus Is On An Adorable Young Girl Who's Smiling At The Camera While Mom Holds Her.

Maternity Care: How to Address Bias and Increase Cultural Humility

Charlene Johnson, RN, MSN
Charlene Johnson, RN, MSN
Nurse manager for Perinatal Services at Kaiser Permanente’s South Sacramento Medical Center

I came across a picture, by the Iranian photographer and artist Bahareh Bisheh, of a little girl, curled up in a fetal position on the ground, laying inside a stick figure of what appeared to be a woman drawn with chalk. As I stared at this artwork, the sad reality struck me that this image could represent the deep loss, isolation, grief, and trauma experienced when a child loses a mother during childbirth. Wanda Barfield, the director of the Division of Reproductive Health at the Centers for Disease Control and Prevention (CDC), encapsulated this idea of loss by saying, “A maternal death is more than just a number or part of a count. It is a tragedy that leaves a hole in a family.”

Black women and childbirth

Childbirth should be one of the most exciting times in a woman’s life, but unfortunately, many Black women have birth experiences filled with anxiety, fear, and frustration. The good news is there are new opportunities for health care teams and organizations to explore and implement programs and approaches to addressing this issue. As a nurse manager for perinatal services at Kaiser Permanente’s South Sacramento Medical Center, I’m proud to say that we are working diligently to improve our self-awareness and enhance communication with our diverse population, all with the goal of delivering exceptional care experiences to our patients and their families.

Throughout the US health care system, miscommunication between clinicians and patients can lead women to feel unheard or even misinformed throughout the birth process, which may result in lasting negative emotional outcomes. For example, Black and Latinx women highlight gaps in communication when receiving care, along with the perception that care teams are not attentive to their emotional and physical needs.

I’ve experienced first-hand the communication challenges that can happen between patient and clinician during childbirth. With my second child, born outside the Kaiser Permanente health care system, I remember vividly asking my nurse for an epidural several times. I was dilated to 4 cm, contracting every 2-3 minutes, and becoming extremely uncomfortable. Every time I would ask for relief, she would downplay my request as if she did not hear me. After one hour of excruciating pain, I finally looked at my husband and began to cry out – which was not my norm. He became upset and demanded that I receive pain management care. Thirty minutes later, I delivered our daughter, without having received an epidural. Some people may say, “Well, at least you did not have to go through the experience of getting an epidural,” but my desire as a patient was to have an epidural. I still remember this negative experience. I did not go back to that health care organization to deliver my third child.

Health care systems addressing equity, implicit bias and racism

If health care systems truly addressed implicit bias and racism, it could make a huge impact by narrowing racial disparities in care. In 2021 the CDC reported that Black women are three times more likely to die from a preventable problem during pregnancy compared to White women. Often, women of color receive suboptimal care because of implicit biases and, as a result, lose their sense of autonomy in the health care decision-making process. Implicit biases are unconsciously formed connections that lead to an unfavorable assessment of a person based on irrelevant factors – such as race or gender. While I’ve witnessed biased interactions and experienced them personally, it was not until May 2020, as the country witnessed the tragic death of George Floyd, that I found my voice and began to share my own stories of racism and unconscious bias.

Part of my job as a nurse manager of perinatal care is to continuously improve care delivery, workflows, communication, and the patient experience. While earning my Master of Science in Nursing, I led a quality improvement project focused on reducing bias through humility and mindfulness practices in the perinatal microsystem. I knew that this part of my education would provide immediate value and insight to my team, so I decided to pilot this work in our South Sacramento labor and delivery unit.

Our team was enthusiastic about the opportunity and implemented the work by using the 5Rs (reflection, respect, regard, relevance, and resiliency) to integrate cultural humility into care practices. This practice in the workplace has us working together to break down biases, improve mutual understanding, and heighten cultural sensitivity when caring for a diverse set of patients. For example, a clinician who overhears a couple arguing in their room post-delivery can apply the 5Rs to reflect on what he/she doesn’t know about the full situation before taking any action. This approach creates room for self-reflection in order to better understand one’s own bias, along with avoiding unnecessary conflicts and upholding respect for patients and their families.

Quality improvement efforts

This project showed that long-lasting biases and stereotypes can be dismantled by introducing mindfulness practices into nursing care. In the same spirit, several Kaiser Permanente regions have developed bias training programs to educate clinicians and staff about how unconscious bias may impact the care they provide to pregnant women. In California, this training is mandated by SB-464, the California Dignity in Pregnancy and Childbirth Act, and we have created an interactive training to support its implementation.

In addition, Kaiser Permanente has recently updated its foundational training for physicians, certified nurse-midwives, and registered nurses who work with maternity patients to include information about maternal health disparities and guidance for providing more equitable care.

Public policy to improve Black maternal health

While individuals can make a big difference in breaking down bias and improving Black maternal health outcomes, public policy plays a pivotal role in advancing this mission. Kaiser Permanente supports policies that increase the availability of implicit bias training for health care clinicians and staff and supports the advancement of research to improve maternal health outcomes. This type of training is now required by law in California.

Promising research areas include examining the signs and symptoms of common pregnancy complications; family planning and the benefits of long-acting, reversible contraception; and structural racism in maternal health care. This type of research can help shape the future of maternal health and support equitable care for all patients. Researchers from across my organization are looking at these issues and others, including the underlying inequalities in maternal mental health and the relationship between race and prematurity.

To move forward as a society, we must begin to address inequities and educate people at every point across the continuum of care. Numerous studies indicate that unconscious bias is a factor in patient outcomes, and I want to do more to address this inequity. I am committed to delivering culturally responsive care that is respectful and equitable for every patient, every time, and working with my team to do the same. As we celebrate and reflect on Black Maternal Health Week, please consider joining me in making a fresh commitment to addressing cultural bias and eliminating inequities in your communities.

Back To Top