Development of an instrument to measure awareness and mitigation of bias in maternal healthcare

BACKGROUND: Implicit bias among maternal healthcare professio-nals contributes to disrespectful care and racial and ethnic disparities in patient outcomes, and there is growing consensus that implicit bias train-ing is a key component of birth equity initiatives. A requirement for implicit bias training for healthcare professionals has become more widespread, but the impact training has is largely unknown, in part, because of a lack of validated instruments. Therefore, there is an urgent need for a psycho-metrically valid instrument for use in the evaluation of implicit bias training. OBJECTIVE: This study aimed to develop a valid and reliable instru-ment to assess implicit bias awareness and mitigation practices among maternal care professionals and that can be used to evaluate interventions aimed at mitigating such bias in clinical practice. STUDY DESIGN: We conducted an instrument development and vali-dation study in 3 phases. In phase 1, item development, we generated a 43-item bank from literature and consultation and established content validity with subject matter experts. In phase 2, instrument development, we administered a revised set of 33 items to 307 nurses and midwives and conducted exploratory factor analysis to demonstrate construct validity and reliability. In phase 3, instrument evaluation, we confirmed the factor structure and compared the means of implicit bias training-exposed and -unexposed participants to further demonstrate construct validity with a representative state sample of 2096 maternal healthcare professionals (physicians, midwives, and nurses). RESULTS: Based on phase 2 results, we retained 23 items for the Bias in Maternal Health Care scale, which showed high internal consistency (Cronbach's alpha, 0.86). We identified 3 subscales, namely a 9-item Bias Awareness subscale (Cronbach's alpha, 0.86), a 7-item Bias Mitiga-tion Practice subscale (Cronbach's alpha, 0.82), and a 7-item Bias Mitiga-tion Self-Efficacy subscale (Cronbach's alpha, 0.81). Validation of the Bias Awareness and Bias Mitigation Practice subscales in phase 3 demon-strated the instrument's high reliability (Cronbach's alpha 0.86 and 0.83, respectively) and discriminating performance among maternal healthcare professionals.CONCLUSION: We developed a reliable and valid instrument for mea-suring awareness and mitigation of bias among maternal healthcare pro-fessionals. It can be used to evaluate implicit bias training and other bias mitigation interventions in maternal healthcare settings.