Perceived Bias and U.S. Perinatal Health Care Quality: Implications for Practice and Policy

Abstract

Introduction:

U.S. maternal mortality rates are high. Inequities in birth outcomes are pervasive. Patient perception of bias during pregnancy-related care, especially among minoritized communities, is a risk factor for adverse perinatal health outcomes. Addressing this may be vital to lowering maternal mortality and improving care. The aim of this review was to explore the association between patient perception of provider bias and U.S. perinatal health care quality in birthing people.

Methods:

Following PRISMA-ScR guidelines, we conducted a scoping review of original published studies (2003–2023) addressing perceived bias/discrimination and perinatal care quality metrics. Both qualitative and quantitative studies were evaluated to formulate a broad conceptualization of the research examining perceived bias and perinatal health care quality.

Results:

Four addressed themes arose from this review that related to the association of perceived bias with: (i) demographic factors such as race/ethnicity and insurance type; (ii) patients’ pregnancy-related health care engagement; (iii) a breakdown in communication and trust between patients and providers; and (iv) patients’ sense of choice/control in their perinatal health care engagement.

Conclusions:

Researchers are using first-person accounts of perceived bias to better understand the etiology of inequitable maternal health statistics in the United States. Preliminary outcomes from this body of work indicate a relationship between the perception of bias, provider relationships, health care engagement, and maternal agency. The role of bias perception on maternal mortality may be an important barrier to improved health outcomes, particularly in minoritized populations.

Introduction

The U.S. experiences poorer perinatal outcomes than other similar, high-income countries.^1,2 In 2023, there were 21 maternal deaths per every 100,000 live births—almost double that of the average for high-income countries.³ These outcomes are exacerbated in minoritized groups, especially among Black birthing people. In 2020, the average maternal mortality rate in the United States was 23.8 deaths per 100,000 live births, whereas for non-Hispanic Black birthing people, it was 55.3.⁴ There are myriad factors proposed that contribute to these outcomes, including structural causes, bias from health care employees, chronic stress from life-long experiences of racism, and the fact that Black individuals are more likely to have preexisting cardiovascular morbidity that increases the risk of maternal mortality.⁵

Prepartum and postpartum care and delivery present opportunities to improve birth outcomes^6

–10. A 2022 report summarizing data from nine maternal mortality review committees found that >80% of maternal deaths in the United States were preventable.¹¹ Quality perinatal care, as described by the Joint Commission, a hospital accrediting organization, should achieve “integrated, coordinated, patient-centered care for clinically uncomplicated pregnancies and births.”¹² Yet, the utilization and experience of prenatal and postnatal health services are worse within minoritized communities.^{7,13

–18} This could be due, in part, to provider biases which have been shown to be associated with patients avoiding care, delaying care, or not adhering to treatment^{19

–27}; a trend that may be more pronounced among birthing people from minoritized communities.^21,22 Implicit bias (a negative attitude against a specific social group of which one is not consciously aware²⁸) and discrimination (the unjust or prejudicial treatment of different groups of people with shared characteristics²⁹) are likely additional contributors to the perception of bias in health care. Unconscious biases held by health care professionals can diminish the quality of care given,³⁰ with many studies finding provider stereotypes and implicit biases to negatively impact quality of health care across various disciplines.^19

–23 However, patient perception of bias and discrimination can be an additional important factor and has been understudied as it relates to quality of care. It is therefore the focus of this review.

The association between perceived bias and birth outcomes among Black birthing people in the United States may be particularly salient. One review of the relationship between perceived discrimination and health among Black Americans found perceived racism to be strongly correlated with negative birth outcomes (with a dose–response relationship), while evidence was less strong for experiences of racism and other health outcomes.²⁶ Importantly, whether discrimination occurs or not, perception of bias itself is of significance because of the variety of adverse mental and physical health outcomes it is associated with.³¹ Part of the difficulty with using the perception of discrimination as a causal measure is both patients underestimating the extent of discrimination they perceive (minimization bias) and overestimating it (vigilance bias or stereotype threat).³² This is of significance to our work as it has been shown that individuals experiencing stereotype threat can experience memory loss, anxiety, reductions in effort or self-control, health care avoidance, and difficulty in adhering to treatment plans, even if discrimination did not occur.^33

–38

The primary objective of this scoping review was to explore the association between perceived bias/discrimination and perinatal care quality in birthing people, with a particular focus on people of color and people with lower incomes (note the term perinatal is used here to include the prenatal, childbirth, and postnatal period). We hope to add to the body of literature that can be used to understand and improve inequitable birth outcomes.

Methods

A scoping review was selected as the study design, following Arksey and O’Malley’s methodology, to address a broad research question and incorporate varied study designs to systematically map the relevant research.³⁹ This work adhered to the Preferred Reporting Items for Systematic Reviews and Meta Analyses-Extension for Scoping Reviews (PRISMA-ScR) protocol (see report in Fig. 1).⁴⁰

FIG. 1.

Flowchart of PRISMA diagram displaying article selection process (note the software Covidence was used to screen references).

The aim of our literature research was to understand the associations between perceived bias and various metrics of perinatal care quality. We define “perinatal care quality metrics” as factors that have a positive or negative association with a perinatal patient’s care experience, and the agency they experienced during the clinical encounter. These metrics were not predetermined but emerged during the literature review process, representing both what participants identified as indicators of care quality and areas researchers sought to examine in relation to the presence of potential bias. Both qualitative and quantitative studies were evaluated to formulate a broad conceptualization of the association between perceived bias, perceived discrimination, and perinatal care quality.

Studies were identified using relevant search terms on PubMed, CINAHL (EBSCO), and Academic Search Ultimate (EBSCO) to find original, peer-reviewed research that examined perceived discrimination and birthing peoples’ experience of perinatal care quality. Search strings included: (perceived OR perception) AND (discrimination OR bias OR racism, OR insurance-based discrimination) AND (Black OR African American OR Hispanic OR Latina OR Native American OR Indigenous OR Medicaid OR low-income) AND (perinatal care OR prenatal care OR maternity care OR birth OR antenatal care OR postnatal care). Bibliographies of relevant studies were also examined and resulted in the inclusion of additional studies.

The criteria for study inclusion were as follows: 1.

Focused on prenatal, postnatal, or hospital birth health care experiences.

Based in the United States—due to the specificity of discrimination, racism, and bias found country to country.

Included either the natural occurrence of patients bringing up their own experiences with perceived discrimination as explanatory models for care received (whether perceived bias was the intended focus of the research or not), or researchers directly inquiring about experiences with perceived discrimination or bias through surveys or interviews, with perceived bias being a predetermined research question.

Provided examples of perceived discrimination were compared to, or associated with, perinatal care quality metrics.

Were published after 2003 and up to 2023—A considerably long timeframe was chosen in part due to the dearth of research on the subject and to aggregate data on how perceived discrimination can be studied and what outcomes could be used to measure its association with perinatal care to guide future research.

Twenty studies were determined eligible for inclusion by one author (R.T.) based on the criteria listed above, using the software Covidence to screen references (Fig. 1).

Charting was conducted iteratively and collaboratively by the investigator team (R.T. and C.E.). A qualitative data analysis approach was employed following Thomas and Harden’s framework for qualitative analysis that involved first conducting line-by-line coding, identifying descriptive themes from said codes, and finally producing analytic themes to assess broader implications.⁴¹ To synthesize quantitative and qualitative data, we used a convergent integrated approach involving “qualitizing” the quantitative data by converting it into themes and categories and following JBI methodological guidelines for mixed-methods reviews.⁴² Inductive coding was utilized. Articles were read and codes were deliberated, and then initial coding was performed by R.T. When codes did not match or new codes were needed, they were created and the articles reviewed again and re-coded until each had been coded with the final set of codes.⁴³ Article themes, as well as the thematic groupings of article codes, were identified by the investigator team and were based on common results or lines of inquiry that were found throughout multiple articles in the selection. This basis was used to determine topics that were recurrent in the literature as opposed to ones specific to a single article. A complete list of codes, examples from each article, and the subsequent themes (perceived bias, provider relationship, choice, and health care engagement) are provided in Table 1.

Table 1.

Coding Method Examples for Studies Chosen

Example	Code
“Women who reported communication problems during prenatal care were substantially more likely to perceive discrimination during their childbirth hospitalization.”⁴⁴	Provider communication
“Reluctance to ask questions in prenatal care was strongly associated with perceptions of discrimination for each reason examined. High scores on the barriers to open discussion scale were also associated with higher chances of perceived discrimination.”⁴⁴	Asking questions Provider communication
“Black and Hispanic women were more likely than white women to report perceived discrimination due to race, language or culture.”⁴⁴	Perceived bias: race Perceived bias: language Perceived bias: culture
“Uninsured women had nearly twice the odds of experiencing any perceived discrimination, and this was driven by reports of race- and insurance-based discrimination.”⁴⁴	Perceived bias: insurance Intersection: race and insurance
“Discrimination and insurance-based discrimination were associated with 7 and 10 percentage point (pp) lower predicted probabilities of attending a postpartum visit”⁴⁵	Appointment attendance
“There was a 7 pp lower predicted probability of discussing birth control for women who had experienced discrimination (81% vs. 88%)”⁴⁵	Choice: birth control discussion
“15 pp lower predicted probability of being asked about depression (64% vs. 79%)” [for women who reported discrimination]⁴⁵	Choice: postpartum depression discussion
“9 pp lower predicted probability of being asked about breastfeeding (57% vs. 66%).” [for women who reported discrimination]⁴⁵	Choice: breastfeeding discussion
“Attending a postpartum visit was less likely for women who experienced discrimination based on language (84.6% vs. 91.0%, p = 0.02), discrimination based on health insurance (75.3% vs. 91.4%, p < 0.001), and any discrimination (80.3% vs. 91.6%, p < 0.001)”⁴⁵	Appointment attendance Perceived bias: language Perceived bias: insurance
“Discrimination on the basis of age (8.44%) or insurance status (8.19%) was most common, and discrimination because of sexual orientation (0.96%) or because of the neighborhood lived in (0.96%) was least common.”⁴⁶	Perceived bias: insurance Perceived bias: sexual orientation Perceived bias: neighborhood lived in
“Women with Medi-Cal were twice as likely to report that they were treated unfairly because of their race/ethnicity, particularly Asian and Pacific Islander women; four times as likely because of the language they spoke; and almost three times as likely because of their health insurance status.”⁴⁷	Perceived bias: race Perceived bias: language Perceived bias: insurance
“Experiencing insurance-based discrimination was associated with receipt of fewer breastfeeding support actions (significant (OR = 0.43, Wald X2 = 10.10, p < 0.05))”⁴⁸	Perceived bias: insurance Choice: breastfeeding discussion
“Experiencing insurance-based discrimination was associated with a greater likelihood of after-delivery birth control discussion.”⁴⁸	Choice: birth control discussion
“The predicted probability of insurance-based discrimination was similar across race/ethnicity among women who had not declined any care, and higher among women who had declined care. However, the increase in the predicted probability of insurance-based discrimination associated with declining care was 31 percentage points for Latina women, compared to 13 percentage points for White women.”⁴⁹	Declining care Perceived discrimination: insurance Intersection: race and insurance
“The full model for trust in provider and prenatal care satisfaction included two predictors: patient-provider communication (PPC) and provider discrimination.”⁵⁰	Trust in provider Care satisfaction Provider communication
“Participants also described perceived discrimination, with providers not wanting to help them or delaying care. One participant stated that ‘whenever we go to our appointments, they don’t really help us, and they don’t seem happy to see us’, for example.”⁵¹	Ignored Delayed care
“Some women reported experiencing discrimination in their prenatal care on the bases of age, insurance type, and behavioral health history.”⁵²	Perceived bias: insurance Perceived bias: age Perceived bias: behavioral health history
“Women actively planned to accommodate their prenatal care appointments into their lives, in terms of time management, transportation costs, etc. This position was almost universally expressed by the women, regardless of whether their prenatal experience was positive or negative.”⁵²	Appointment attendance
“Most women felt like they were being treated differently because of Medicaid insurance; and some women felt their treatment was influenced by their race.”⁵³	Perceived bias: insurance Perceived bias: race
“Dismissive and biased interactions were particularly common around the issue of contraception. Women described numerous instances where they felt an injection (Depo-Provera) was being forced on them during recovery from birth.”⁵³	Choice: Birth control discussion
“Women talked about being dismissed in encounters, and some felt that providers believed they didn’t need to know or weren’t smart enough to know.”⁵³	Dismissed
“Women primarily talked about difficulties communicating with PNC providers.”⁵³	Provider communication
“Several Women expressed perceptions of differential treatment due to their minority race/ethnicity or socio-economic status. One Hispanic woman felt that she was treated poorly because she did not have health insurance. ‘I’m not saying that they treated her differently because she was Black, but because she had insurance’, she commented.”⁵⁴	Perceived bias: insurance Perceived bias: race Perceived bias: socioeconomic status
“As another woman shared, ‘It depends on the money you make. That’s how I feel. It depends on whether you have Medicaid or insurance. When I was on insurance they treated me like a queen. But when I was off insurance they like put me in a back room.'”⁵⁴	Ignored
“Participants identified three areas of perceived discrimination based on: (1) insurance or income status, (2) race, and (3) lifetime experiences of racial discrimination.”⁵⁵	Perceived bias: insurance Perceived bias: race Perceived bias: socioeconomic status Perceived bias: lifetime experiences of racial discrimination
“Women described being treated differently by support staff and providers based on type of insurance (public versus private), including perceiving a lower quality of care.”⁵⁵	Care satisfaction
“Women described perceptions of unintentional racism, such as stereotypes about African Americans, for example, in the case of a woman being asked about crack use or another being asked about whether the father of the baby was involved.”⁵⁵	Stereotypes
“Brooke found hospitals to be particularly uninviting for Black women, and was aware of the visible, overt power exercised within hospital settings. She reflected on her perceived threat, based on recent media publications surrounding the increased maternal mortality rates among Black American women. ‘I had to stop listening to NPR and I had to stop reading books. I’m like, Nope, they’re [obstetricians and hospital staff] going to kill me. I’m not going to hospital. This is why delivering at home is much better.'”⁵⁶	Declining care/appointment attendance/disengagement with healthcare Perceived bias: race
“Mothers were restricted to various positions, denied pain management, dismissed, and given procedures and medications without consent. Many mothers alluded to experiences with explicit racism.”⁵⁶	Choice: pain management Choice: birth plan Choice: medical intervention
“The denial of pain management for these mothers may have stemmed from inherently racist and stereotypical beliefs regarding the pain tolerance of Black Americans and is another clear example of the overt power exercised in hospital settings.”⁵⁶	Stereotypes
“Some respondents, like Lila, were so keenly aware of the overt power that hospital-based providers exercised and the asymmetrical power relations that they felt intimidated initiating basic tasks like using the restroom. ‘I did not feel in control. I felt like I had to kind of do what they said, to be quite honest. Even though things got better the second time, I was still intimidated by requesting: Can I get up and go to the bathroom? Can I sit in a shower? I felt intimidated asking those questions.'”⁵⁶	Asking questions
“Women identified themselves by the type of insurance they had, for example, Medicaid. Insurance type was described as a reason women felt they were treated differently.”⁵⁷	Perceived bias: Insurance
“Women described being dismissed and treated rudely because of their race.”⁵⁷	Dismissed Perceived bias: race
“Some women felt like it was difficult to ask questions: ‘Sometimes it is just easier to look it up or easier to ask my mom or somebody in my family-- [it] shouldn’t be that way. I feel like [the doctors] should communicate [what] was going on.'”⁵⁷	Asking questions Provider communication
“Negative experience themes included being considered a low priority, not being able to get help, being ignored, not listened to, not believed, not treated with respect, rushed, not having their preferences considered, being traumatized, and having their visitors treated poorly.”⁵⁷	Ignored Provider communication Choice Trauma Rushed Visitors being treated poorly
“One participant shared her experience during a postpartum hemorrhage in which she received no information about what was happening to her and was treated as if she was not a person who was part of the situation and deserving of information.”⁵⁸	Communication
“Another participant shared her experience of being ignored when she wanted to know what happened during her traumatic birth experience.”⁵⁸	Ignored
“Many participants noted differences in care due to racism, classism (poverty), education, and public insurance.”⁵⁸	Perceived bias: race Perceived bias: socioeconomic status Perceived bias: insurance Perceived bias: education
“Even in the absence of overt displays of bias from providers, participants often felt subject to stereotyping that perpetuated feelings of marginalization. The intersections of poverty and race were also noted in these exemplars describing judgment from providers.”⁵⁸	Stereotypes Intersection: race and socioeconomic status
“Respondents who indicated experiencing discrimination in healthcare at least a few times a year were 3.17 times more likely to have an unpleasant prenatal care visit (p < 0.001) compared to those who experienced discrimination at most once a year.”⁵⁹	Care satisfaction
“Respondents who believed that their race contributed to discrimination in the healthcare system were 2.45 times more likely to have an unpleasant prenatal care visit (p = 0.018) compared to those who said “no” to race being a contributing factor. Respondents who believed that their age contributed to discrimination in the healthcare system were 2.74 times more likely to have an unpleasant prenatal care visit (p = 0.001) compared to those who said “no” to age being a contributing factor. Respondents who believed that their physical appearance contributed to discrimination in the healthcare system were 2.83 times more likely to have an unpleasant prenatal care visit (p = 0.01) compared to those who said “no” to physical appearance being a contributing factor.”⁵⁹	Perceived bias: race Perceived bias: age Perceived bias: physical appearance
“Specific to race, almost all participants attributed disrespectful language and conversations with staff as a common experience they have throughout their day to day lives, and were not surprised that healthcare teams and systems perpetuated those experiences, one participant said: ‘And I also wonder how much of the advice or—yeah, advice they give you is based on our race because I was Hispanic, and I was a teenager and I got pregnant, the nurse assumed I was going to be pregnant a whole lot of times and she suggested right away I should get rid of my child without asking me if I wanted to. So, it’s based on my race?'”⁶⁰	Perceived bias: race
“Most of the women described situations where they did not believe their wishes were respected. In addition, many described feeling ignored or that they were receiving care that was different and of a lower caliber than women of other races/ethnicity or with private insurance.”⁶⁰	Ignored Dismissed Perceived bias: race Perceived bias: insurance
“Other participants cited their race, ethnicity or language spoken as the cause of the disrespectful treatment.”⁶⁰	Perceived bias: ethnicity Perceived bias: language
“Another participant said: ‘Well, for one, I just feel like—I don't know. I know everyone's not like that, but when you have MediCal and come into the doctor's office or if they're seeing primarily MediCal, they just already have this stereotype already on you and I just got – a lot of times I felt like the doctors kind of talk down to me.'”⁶⁰	Stereotype
“‘Oh, boy. I’m on Medicaid, you know they’re not going to take care of me.’ And, so, they’re so reluctant to go, and they know that even if they do go, they don’t know if they’re getting the care they need.” This same sentiment was expressed by other women who described that, from their perspective, those with private insurance were treated with more dignity, respect, and compassion.”⁶¹	Perceived bias: insurance Respect
“One participant explained that she felt that Black women are more often pressured to deliver via Cesarean section.”⁶¹	Choice: medical intervention
“The perception of healthcare provider bias led to discomfort for women when deciding whether and how to voice questions and concerns during pregnancy.”⁶¹	Asking questions
“Two women described an element of coercion that they felt was influenced by racism or the government. A 35-year-old African American woman with three pregnancies and one child, who refused hormonal contraception, felt that instead of listening to patients, physicians were single-minded in their desire to have her use contraception.”⁶¹	Choice: Birth control discussion
“I just know that for Black moms, you will never be treated like your White friends. Don’t expect to get the same treatment. I made that mistake thinking because I am someone educated, and I was informed about the birth process and everything, it wasn’t like I was going into it with no knowledge at all, and this [nonconsensual cesarean section] still happened to me.”⁵³	Choice: cesarean

Theme	Codes
Perceived bias	- Race - Language - Culture - Insurance - Sexual orientation - Neighborhood lived in - Socioeconomic status - Education - Physical appearance - Behavioral health history - Lifetime experiences of racial discrimination - Intersection: race and insurance
Provider relationship	- Provider communication - Asking questions - Trust in provider - Care satisfaction - Ignored - Delayed care - Dismissed - Stereotypes - Respect
Choice	- Birth control discussion - Postpartum depression discussion - Breastfeeding discussion - Pain management - Birth plan - Medical intervention - VBAC - Episiotomy - Cesarean
Healthcare engagement	- Appointment attendance - Declining care - Disengagement with healthcare

Note all examples for all codes for each article were not included, especially if an example was already present for a given article, if the code was represented in a data table, or if the code was represented over a longer narrative segment.

Table 2.

Index of Studies

Study	Patient-reported communication quality and perceived discrimination in maternity care
Reference number	⁴⁴
Authors	Attanasio L, Kozhimannil KB
Year	2015
Location	United States (web-based survey)
Quantitative/qualitative	Quantitative
Period of perinatal care	Prenatal, childbirth
Population	People aged 18–45, who gave birth in a hospital in the United States between 2011 and 2012, including non-Hispanic White, non-Hispanic Black, and Hispanic birthing people (n = 169). Those who identified as other racial/ethnic groups were excluded due to small sample size.
Perceived bias	Primary focus
Themes of bias	Racial, insurance status, language, and culture. Intersection of race and insurance status
Major proposed outcome of perceived bias	Not comfortable asking questions, communication problems
Study	Perceived discrimination during the childbirth hospitalization and postpartum visit attendance and content: evidence from the listening to mothers in California survey
Reference number	⁴⁵
Authors	Attanasio LB, Ranchoff BL, Geissler KH.
Year	2021
Location	California
Quantitative/qualitative	Quantitative
Period of perinatal care	Postnatal
Population	People over 18 years old who gave birth in a hospital in California between September 1, 2016, and December 15, 2016 (N = 2295). Authors report that Black women, women with midwife attended births, and women with VBACs were oversampled
Perceived bias is	Primary focus
Themes of bias	Racial, insurance status, language
Major proposed outcome of perceived bias	Negatively correlated with breastfeeding support, postpartum depression screening, being offered birth control
Study	Perceived Discrimination During Prenatal Care, Labor, and Delivery: An Examination of Data From the Oregon Pregnancy Risk Assessment Monitoring System, 1998–1999, 2000, and 2001
Reference number	⁴⁶
Authors	De Marco M, Thorburn S, Zhao W
Year	2008
Location	Oregon
Quantitative/qualitative	Quantitative
Period of perinatal care	Prenatal, childbirth
Population	People who had a live birth in Oregon from 1998 to 2001 (N = 5762). Authors report that African Americans, American Indian/Alaskan Native, Asian/Pacific Islander, and Hispanic mothers were oversampled
Perceived bias is	Primary focus
Themes of bias	Insurance status, age, sexual orientation, neighborhood lived in
Major proposed outcome of perceived bias	No association
Study	Women’s experience of agency and respect in maternity care by type of insurance in California
Reference number	⁴⁷
Authors	Declercq, Sakala, and Belanoff
Year	2020
Location	California
Quantitative/qualitative	Quantitative
Period of perinatal care	Prenatal, postnatal, childbirth
Population	People over 18 years old who gave birth in a hospital in California between September 1, 2016, and December 15, 2016, spoke English or Spanish, were residents of California, had singleton birth, and were living with their baby at the time of survey participation (N = 2318). The authors purposefully oversampled Black birthing people, people who had VBACs, and people who had a midwife-attended birth
Perceived bias is	One facet of care experience
Themes of bias	Racial, insurance status, language. Intersection of race and insurance status.
Major proposed outcome of perceived bias	Participants with Medicaid felt more discriminated against, also offered less services than people with private insurance, including: breast feeding supports, postpartum depression screening, whether or not to have VBAC and episiotomy
Study	Perceived Discriminatory Factors that Impact Prenatal Care Satisfaction and Attendance Among Adolescent and Young Adult Couples
Reference number	⁵⁹
Authors	Dillon B, Albritton T, Saint Fleur-Calixte R, Rosenthal L, Kershaw T
Year	2020
Location	Southern Connecticut
Quantitative/qualitative	Quantitative
Period of perinatal care	Prenatal
Population	Young couples (N = 296) with mothers aged 14–21 and fathers 14 years or older, 48.6% of participants were Black, 36.5% were Latinx, 10.5% where White, and 4.4% as other races/ethnicities
Perceived bias is	Primary focus
Themes of bias	Race, age, physical appearance
Major proposed outcome of perceived bias	No association
Study	Insurance-Based Discrimination During Prenatal Care, Labor, and Delivery: Perceptions of Oregon Mothers
Reference number	⁴⁸
Authors	Thorburn S, De Marco M
Year	2010
Location	Oregon
Quantitative/qualitative	Quantitative
Period of perinatal care	Prenatal, childbirth
Population	People who had a live birth in Oregon from 1998 to 2001 (N = 5762). Authors report that African Americans, American Indian/Alaskan Native, Asian/Pacific Islander, and Hispanic mothers were oversampled
Perceived bias is	Primary focus
Themes of bias	Insurance status
Major proposed outcome of perceived bias	Negatively correlated with breastfeeding support. Positively correlated with being offered birth control
Study	African American Women and Prenatal Care: Perceptions of Patient–Provider Interaction
Reference number	⁵⁰
Authors	Dahlem CHY, Villarruel AM, Ronis DL
Year	2015
Location	Southeastern Michigan
Quantitative/qualitative	Quantitative
Period of perinatal care	Prenatal
Population	Black birthing people (N = 204) and providers (N = 21), participants were included if they were 18–45 years old, identified as African American, and were proficient in English
Perceived bias is	Primary focus
Themes of bias	Low perception of bias
Major proposed outcome of perceived bias	Trust lowered by discrimination. Poor patient–provider communication had negative association with trust and prenatal care satisfaction
Study	Declined care and discrimination during childbirth hospitalization
Reference number	⁴⁹
Authors	Attanasio LB, Hardeman RR
Year	2019
Location	United States (web-based survey)
Quantitative/qualitative	Quantitative
Period of perinatal care	Prenatal
Population	People aged 18–45, who gave birth in a hospital in the United States between 2011 and 2012 (N = 2400), 54.5% were White, 15.3% were Black, 23.2% were Latina, and 7% identified as other. 37% had Medicaid, 46% had private insurance, and 40% were primigravid
Perceived bias is	One facet of care experience
Themes of bias	Racial, insurance status. Intersection of race and insurance status
Major proposed outcome of perceived bias	Perceived discrimination positively correlated to participants declining prenatal care
Study	Perceived discrimination during prenatal care at a Community Health Center
Reference number	⁶²
Authors	Prater C, Cohen L, Carter EB, Kuebee B, Tepe M, Keegan M
Year	2023
Location	St. Louis, Missouri
Quantitative/qualitative	Quantitative
Period of perinatal care	Prenatal, childbirth
Population	Poeple who were age 18 years and older (N = 95) and who received prenatal care and delivered at the study site during 2020–2021
Perceived bias (primary focus or one facet of care experience)	Primary focus
Themes of bias	Not specified
Major proposed outcome of perceived bias	Perceived discrimination is significantly associated with reporting being treated with less respect. No significant association between perceived bias with perceptions of courtesy, poor service, being treated as not smart, not being listened to, and the provider acting as if they’re better than the patient
Study	Negotiating Patient–Provider Power Dynamics in Distinct Childbirth Settings: Insights from Black American Mothers. Societies
Reference number	⁵⁶
Authors	West R, Bartkowski JP
Year	2019
Location	San Antonio, Texas
Quantitative/qualitative	Qualitative
Period of perinatal care	Childbirth
Population	Adults who self-identified as Black American were ages 18–40, and had given birth in the last 5 years in San Antonio (N = 20)
Perceived bias is	One facet of care experience
Themes of bias	Race
Major proposed outcome of perceived bias	Not comfortable asking questions, perception of being stereotyped. Perceived discrimination positively correlated to patients disengaging from healthcare and negatively correlated to patients feeling they had autonomy in their pain management, birth plan, cesarean section, and other medical intervention choices
Study	Information and power: Women of color’s experiences interacting with health care providers in pregnancy and birth
Reference number	⁵⁸
Authors	Altman MR, Oseguera T, McLemore MR, Kantrowitz-Gordon I, Franck LS, Lyndon A, Intersection: race and socioeconomic status
Year	2019
Location	San Francisco, California
Quantitative/qualitative	Qualitative
Period of perinatal care	Childbirth
Population	People who were 18 years or older, self-identified as a person of color, and were six weeks to one year postpartum (N = 22)
Perceived bias is	Primary focus
Themes of bias	Race, insurance status, socioeconomic status, education. Intersection of race and insurance status. Intersection of race and economic status
Major proposed outcome of perceived bias	Not comfortable asking questions, feeling ignored, perception of being stereotyped. Negative association with communication
Study	Perceptions of Coercion, Discrimination and Other Negative Experiences in Postpartum Contraceptive Counseling for Low-income Minority Women
Reference number	⁶¹
Authors	Yee LM, Simon MA
Year	2011
Location	Chicago, Illinois
Quantitative/qualitative	Qualitative
Period of perinatal care	Postnatal
Population	English-speaking women age 18 years and older who had given birth at the clinical site and attended the women’s outpatient ambulatory care clinic for antenatal care (N = 30). All participants were of minoritized identities (11 Hispanic participants, 19 African American participants) and received public assistance for medical care
Perceived bias (primary focus or one facet of care experience)	One facet of care experience
Themes of bias	Racial
Major proposed outcome of perceived bias	Being pressured to use contraception
Study	Structural and Socio-cultural Barriers to Prenatal Care in a US Marshallese Community
Reference number	⁵¹
Authors	Ayers BL, Purvis RS, Bing WI, Rubon-Chutaro J, Hawley NL, Delafield R, et al.
Year	2018
Location	Arkansas
Quantitative/qualitative	Qualitative
Period of perinatal care	Prenatal
Population	Marshallese mothers living in Arkansas who were above 18 years old (N = 43). 60.7% had Medicaid/Medicare, the rest had private insurance, employer-sponsored insurance, or were on their partner’s plan
Perceived bias is	One facet of care experience
Themes of bias	Race, age
Major proposed outcome of perceived bias	Not comfortable asking questions. Perception of delayed care. Negative association with appointment attendance
Study	Understanding Perspectives of African American Medicaid-Insured Women on the Process of Perinatal Care: An Opportunity for Systems Improvement
Reference number	⁵³
Authors	Roman LA, Raffo JE, Dertz K, Agee B, Evans D, Penninga K, et al.
Year	2017
Location	Michigan
Quantitative/qualitative	Qualitative
Period of perinatal care	Prenatal, postnatal
Population	Medicaid-insured Black birthing people who were above 18 years old, spoke English, and had given birth in the last 12 months (N = 21)
Perceived bias is	One facet of care experience
Themes of bias	Race, insurance status
Major proposed outcome of perceived bias	Information withheld, not comfortable asking questions, being dismissed, and perception of being stereotyped. Some patients felt birth control was forced on them due to discrimination. Perceived bias reported as part of a constellation of barriers to attending appointments
Study	Providing health care to low-income Women: a matter of trust
Reference number	⁵⁴
Authors	Sheppard VB, Zambrana RE, O’Malley AS
Year	2004
Location	Three clinics in the United States: one rural, two urban
Quantitative/qualitative	Qualitative
Period of Perinatal Care	Prenatal
Population	Medicaid-insured, low-income people who were pregnant or had delivered in past 12 months (N = 33). Twenty-three participants were African American, six were White, two were Hispanic, and two were multiracial
Perceived bias is	One facet of care experience
Themes of bias	Race, insurance status, socioeconomic status.
Major proposed outcome of perceived bias	Information withheld. Ignored. Negative association with willingness to follow provider’s advice
Study	Just Because You Have Ears Doesn’t Mean You Can Hear”—Perception of Racial-Ethnic Discrimination During Childbirth
Reference number	⁵⁷
Authors	Janevic T, Piverger N, Afzal O, Howell EA
Year	2020
Location	New York City
Quantitative/qualitative	Qualitative
Period of perinatal care	Childbirth
Population	Latina and Black people who had given birth in the last 12 months and spoke Spanish or English (N = 27)
Perceived bias is	Primary focus
Themes of bias	Race, insurance status, age
Major proposed outcome of perceived bias	Not comfortable asking questions, felt dismissed/ignored, positive communication negatively correlated to perceived discrimination. Patients reported feeling as if they could not get help when they needed it
Study	Health care experiences of pregnant, birthing and postnatal women of color at risk for preterm birth
Reference number	⁶⁰
Authors	McLemore MR, Altman MR, Cooper N, Williams S, Rand L, Franck L
Year	2018
Location	Fresno, Oakland, San Francisco
Quantitative/qualitative	Qualitative
Period of perinatal care	Prenatal, postnatal, childbirth
Population	People of color at risk for preterm birth who were over 18 years old and spoke English or Spanish (N = 54)
Perceived bias is	One facet of care experience
Themes of bias	Race, insurance status, language
Major proposed outcome of perceived bias	Perception of being stereotyped, ignored, and dismissed
Study	Community perspectives on the racial disparity in perinatal outcomes
Reference number	⁶³
Authors	Kalata M, Kalata K, Yen H, Khorshid A, Davis T, Meredith J
Year	2020
Location	Denver, Colorado
Quantitative/qualitative	Qualitative
Period of perinatal care	Prenatal, childbirth
Population	Women who self-identified as African American (N = 27), were ages 18–80, spoke English, and had been pregnant at least once to 20 or more weeks’ gestation, and spoke English
Perceived bias (primary focus or one facet of care experience)	Once facet of care experience
Themes of bias	Race, insurance status, age, education, marital status
Major proposed outcome of perceived bias	Perceived implicit bias associated with increased pressure to deliver via cesarean and decreased ability to ask questions, receive respectful/compassionate care, and voice concerns
Study	“You Learn to Go Last”: Perceptions of Prenatal Care Experiences among African-American Women with Limited Incomes
Reference number	⁵⁵
Authors	Salm Ward TC, Mazul M, Ngui EM, Bridgewater FD, Harley AE
Year	2013
Location	Milwaukee, Wisconsin
Quantitative/qualitative	Qualitative
Period of perinatal care	Prenatal
Population	Low-income, self-identified African American women, over 18 years old with a child under one year old who had attended at least one prenatal visit in Milwaukee (N = 31)
Perceived bias is	One facet of care experience
Themes of bias	Race, status, socioeconomic status
Major proposed outcome of perceived bias	Perception of being stereotyped. Perceived lower quality of care overall
Study	Women’s Experiences with Prenatal Care: A Mixed-Methods Study Exploring the Influence of the Social Determinants of Health
Reference number	⁵²
Authors	D’Angelo KA, Bryan JK, Kurz B
Year	2016
Location	Connecticut
Quantitative/qualitative	Mixed methods
Period of perinatal care	Prenatal
Population	People over 18 years old who were pregnant or under 1 year postpartum (N = 47). Participants were largely Black/African American, Hispanic/Latina, and low income. West Indian and White participants were also included
Perceived bias is	One facet of care experience
Themes of bias	Insurance status, age, behavioral health history
Major proposed outcome of perceived bias	Low barriers to appointment attendance

Rigor

The investigator team collaborated in person (Los Angeles) and through virtual meetings to ensure methodological alignment and resolve uncertainties (if any) regarding study selection, data extraction variables, or other methodological issues. Disagreements, if any, were navigated by team-based consultation with A.V. serving as a “tiebreaker” if necessary. However, no disagreements arose and no independent review was required. The authors also practiced reflexivity throughout their analysis and how their professional and personal perspectives may have influenced their understanding of the themes. The research team included a cardiologist specializing in women’s cardiovascular health, a nursing master’s student with doula experience, and a tenured professor of human anatomy and physiology. Among them were individuals identifying as White and Latina.

Results

Description and studies reviewed (see Table 2 for an index of studies)

Of the 20 articles included, nine were quantitative (survey based),^{44

–50,59,62} and ten were qualitative and either composed of in-depth interviews,^56,58,61 focus groups,^{51,53,54,57,60,63} or a combination of the two.⁵⁵ One article was mixed methods—using focus groups, interviews, and surveys.⁵² Fifteen studies assessed prenatal care,^{44,46

–55,59,60,62,63} five studies addressed postnatal care,^{45,47,53,60,61} and 10 studies examined labor and delivery.^{44,46
–48,56
–58,60,62,63} Seven of the studies did not have an explicit demographic focus, but sampled general populations of birthing people over the age of 18 within a geographic bounds who were pregnant or had given birth recently,^{44

–48,52,62} five focused on Black birthing people’s experiences,^{50,53,55,56,63} four focused on birthing people who have low incomes or are Medicaid-insured,^53
–55,61 four focused on people of color,^49,58,60,61 and three focused on other groups (young couples,⁵⁹ Black and Latina birthing people,⁵⁷ and Marshallese birthing people⁵¹). Nine studies focused primarily on perceived discrimination,^{44
–46,48,50,57
–59,62} and 11 studied perceived discrimination as one facet of patient satisfaction/perception of care experiences.^{47,49,51

–56,60,61,63}

Four major themes arose in this review regarding the association of perceived bias with:

demographic factors such as race/ethnicity and insurance type.

patients’ pregnancy-related health care engagement.

a breakdown in communication and trust between patients and providers.

patients’ sense of choice/control in their perinatal health care engagement.

Theme 1: The association of perceived bias with demographic factors such as race/ethnicity and insurance type

Nineteen of the 20 studies investigated which demographic factors the participants believed contributed to why they were being discriminated against. Among the qualitative studies, race/ethnicity and insurance type were the most frequently occurring perceived causes of bias. The intersections between insurance status and race was also of concern in four studies.^44,47,49,58 Perceived racial discrimination appeared in all 11 of the qualitative studies,^{51,53

–61,63} but was not reported in the mixed-methods study by D’Angelo and colleagues, which was the largest and most diverse sample.⁵² Insurance-based discrimination, namely being insured by Medicaid, was perceived by participants in eight^{52

–55,57,58,60,63} of the studies, and was the most pervasive form of perceived discrimination in two of the studies.^53,55 As a participant in one study expressed, “In the hospital and [with] different healthcare providers, I did feel the discrimination, I did feel like I was less than because I had [Medicaid].”⁵²

Socioeconomic status, age, and language were also common themes—participants recalled perceived discrimination due to socioeconomic status in three of the studies,^54,55,58 age in six,^{46,51,52,57,59,63} and language in four of the studies.^44,45,47,60

Out of eight quantitative studies examining types of perceived bias, insurance-based bias was the most frequently cited, reported in six of the eight studies.^44

–49 Three studies found insurance-based perceived discrimination to be the most commonly occurring or impactful participant-reported form of discrimination,^44,45,47 one found it to be a close second after age,⁴⁶ and another a close second to the difference of opinion with a medical professional.⁴⁹ In two of these studies, the intersection of race and insurance was also assessed. In one instance, people of color were more likely to report insurance-based perceived discrimination (insurance type was not specified) compared to non-Hispanic White participants (20% versus 13%).⁴⁴ The other study found that a higher percentage of Medicaid-insured patients reported racial discrimination (6.5% versus 2.3%).⁴⁷ Perceived racial discrimination was assessed in five of the quantitative studies,^{44,45,47,49,59} but was only the most common in one (along with age).⁵⁹

Theme 2: The association of perceived bias with patients’ pregnancy-related health care engagement

Another recurring theme in both quantitative and qualitative research was the association of perceived discrimination with patients’ willingness to go to the hospital for subsequent perinatal care. In both qualitative and quantitative studies, the results were conflicting.

In an interview-based study among Black birthing people who were mostly low-income, participants reported opting out of hospital births because of their fears of experiencing discrimination in the hospital.⁵⁶ One participant cited discriminatory hospital experiences as her motivation for pursuing homebirth, remarking, “Nope, they’re [obstetricians and hospital staff] going to kill me. I’m not going to the hospital.” Participants who did have births at the hospitals felt perceived discrimination resulted in dangerously poor care. A study among Marshallese birthing people in America found perceived discrimination among providers to be a barrier to attending prenatal care.⁵¹ In another qualitative study, prenatal visit attendance was not found to be associated with perceived discrimination; this was attributed to the importance participants placed on the appointments and their willingness to make sacrifices to attend them.⁵²

One quantitative study found respondents who reported perceived discrimination were less likely to attend their postpartum care visit compared to respondents who did not report perceived discrimination (80.3% versus 91.6%).⁴⁵ Another study found that participants were 3.89 times more likely to decline procedures during childbirth if they felt the hospital staff discriminated against them.⁴⁹ Two others found perceived discrimination to have no association with appointment attendance however.^46,59

Theme 3: The association of perceived bias with a breakdown in communication and trust between patients and providers

The most commonly reported result of perceived bias in qualitative studies was the perception by patients that practitioners were not taking their concerns seriously, dismissing them, not listening to them, or ignoring them.^{53,54,56
–58,60,63} In one study of Black patient’s experience of birth, a participant stated that hospital staff did not take her claim seriously, that “something was not right” until she explained that she was not on Medicaid but was a registered patient of the hospital.⁵⁶ She perceived that they had assumed she was on Medicaid, and because of this, and being Black, had taken her less seriously. In this instance, there was near fetal loss due to a prolapsed cord until, according to the patient, she managed to change a nurse’s perception of her.⁵⁶

Other aspects of patient–provider communication reported in qualitative studies included patients feeling like perceived discrimination from providers resulted in information being withheld,^53,54 difficulty asking questions,^{51,53,56
–58} and negative assumptions/stereotypes being applied to them in the medical setting.^{53,55,56,58,60} One participant outlined how she felt that the advice she received from physicians was influenced by stereotypes on her race and age, stating, “I also wonder how much of the advice they give you is based on our race because I was Hispanic, and I was a teenager, and I got pregnant. The nurse assumed I was going to be pregnant a whole lot of times and she suggested right away I should get rid of my child without asking me if I wanted to or not.”⁶⁰

Three of the quantitative studies examined whether there was a connection between perceived discrimination and poor patient–provider communication. Data from the “Listening to Mothers” survey found that participants who perceived a high level of discrimination had a 2.11 times higher chance of reporting barriers to communication and 6.42 times higher reluctance to ask questions during prenatal care.⁴⁴ One study found perceived discrimination to have a small, but insignificant inverse relationship with trust in provider (B = −0.14, SEB = 1.34, p > 0.011).⁵⁰ In another quantitative study perceived bias was significantly associated with not feeling listened to, with 14% of those who reported any discrimination also reporting feeling unheard (the mean for the total population was 1.26, with 1 = always feeling heard/listened to and 5 = never feeling heard/listened to).⁶² Meanwhile, perceived bias had positive but statistically insignificant relationships with being treated with courtesy and being talked down to.⁶²

Theme 4: The association of perceived bias with patients’ sense of choice/control in their perinatal health care engagement

Several studies used patient involvement in decision-making, and whether providers addressed certain topics (e.g., birth control and postpartum depression), as quality metrics for perinatal care. The association between perceived discrimination and patient autonomy was observed in five qualitative studies. Two studies found that participants felt birth control was being forced on them due to stereotypes about their race and insurance status.^53,61 One respondent reported, “You know, I notice with African American women, they quick want to give us shots or birth control immediately after we have our children. I was like, is that for to stop the bleeding, she says: No, you need to be on birth control.”⁵³ In two studies, participants felt that they were being pressured into cesareans due to perceived discrimination from providers.^56,63 In another study, participants reported lack of autonomy in their birth plan, pain management, and other medical intervention choices due to perceived bias.⁵⁶

Patient choice and options presented to patients were measured by two of the quantitative studies.^45,48 One study found postpartum patients who reported perceived bias to have a 7% lower probability of discussing birth control, a 15% lower probability of being asked about postpartum depression, and a 9% lower probability of being asked about breastfeeding, compared with patients who did not report perceived discrimination.⁴⁵ Another found insurance-based perceived discrimination to be associated with a 48% lower probability of receiving breastfeeding support (OR = 0.52, 95% CI: 0.34–0.79, p < 0.01) and a 1059% higher probability of having birth control discussed (OR = 11.59, 95% CI: 3.56–37.77, p < 0.001).⁴⁸

Discussion

Much of the prior research addressing perceived bias in perinatal care has focused on broader questions of birthing peoples’ perception of their care. Our work revealed that patients in perinatal care settings commonly associate their experiences of discrimination with race and type of insurance. The primary association with perceived bias was a reported poor patient–provider relationship. Additionally, perceived bias was associated with reduced autonomy in perinatal clinical decision-making. Our findings are summarized and discussed in the context of quality metrics for perinatal care via the major themes highlighted by our work, persistent knowledge gaps, and contributions from qualitative and quantitative work to our findings.

The perception of insurance status-based bias was a common theme in this review (seen in 15 of 20 studies) and raises several questions about how insurance status may be associated with perinatal care quality. Insurance status has been reported to affect birth outcomes. For example, data from 2014–2016 in Washington show that patients with Medicaid had maternal mortality rates 3.5 times higher,⁶⁴ and infant mortality rates nearly twice as high,⁶⁵ compared to patients with private insurance. These data likely reflect additional factors associated with Medicaid coverage, such as socioeconomic status, care access, and health care reimbursement.⁶⁶ However, perceived provider bias based on insurance type might also play a role. Our literature research indicates that this might be an under-examined form of bias that could be an important part of perinatal health care quality and should be further investigated.

The most common explicit focus of articles in this review was racial discrimination. This research is rich and shows the progress researchers are making to understand the role of racism in perinatal health care, considering the recent awareness of racial inequities in maternal outcomes in America.⁶⁷ For instance, a search on Google Scholar for racism and maternal health for articles published in 2000 reveals only 97 results, compared to 2940 results for articles published in 2024. The studies we reviewed also often showed the intersection between race and insurance status to be relevant to patients’ experiences of perceived bias. Prior work addressing intersectionality in perceived discrimination in health care has shown that minoritized identities (such a female biological sex, low-income, sexual minority status, or minority race) amplify the perception of bias and stigma and lead to limitations of care.^68

–71 Conversely, one large study found race has a more significant impact on maternal outcomes for Black birthing people, while insurance status has an insignificant effect when considered alongside race.⁷² This, and research showing that education and income level are often not sufficient explanatory models for worse outcomes for Black patients, indicate that perceived bias and racism are likely drivers of poor outcomes.^73,74

The association of perceived discrimination with the quality of the patient–provider relationship was the most prevalent associative theme found in this literature review. Patients often felt that they were being dismissed, that providers were withholding information, that they could not ask their providers questions, and that negative stereotypes were being applied to them. These key factors illustrate how perceived bias erodes the patient–provider relationship and should be considered when developing communication education for health care providers and staff. Other reviews exploring minoritized communities’ experiences within perinatal care also found adequate information, trust, free-flowing communication, respect, and lack of stereotyping to improve patients’ experiences of care and act as incentives to attending appointments.^75,76 These reviews additionally emphasized the importance of timely care, unrushed interactions with clinicians, and a lack of language barriers, as important factors for high-quality care.^75,76 However, these factors were not studied or examined alongside perceived discrimination in the studies reviewed, thus we did not find these aspects of care to be associated with perceived bias.

Several important indicators of maternal choice and control (such as the choice of receiving an episiotomy or being screened for postnatal depression) were found to negatively correlate with the perception of bias. These data suggest that perceived bias has a measurable impact on the health care experience of birthing people.

One variable that had conflicting evidence was the discussion of birth control. One qualitative study found that participants perceiving bias reported providers discussing birth control more often than those who did not perceive bias,⁴⁸ while another study found the opposite.⁴⁵ Medicaid-insured people of color in two of the qualitative studies reported feeling pressured to use birth control, linking this to discrimination.^53,61 This finding may echo historical cases of coerced sterilization and medical maltreatment of Black, Latina, Puerto Rican, and Native American women in the twentieth century in the United States,^77,78 which researchers have found to have a lasting effect on trust in medical institutions within these populations.^79,80 Thus, perception of bias in the discussion of birth control could depend on the patient–provider relationship and mode of communication, emphasizing the need for providers to approach the topic with sensitivity and remain aware of possible implicit biases in their communication.

While participants in interviews and focus groups often cited perceived discrimination as a deterrent for going to the hospital, this was only found in one of the three large survey-based studies.⁴⁵ In addition, there were no similarities in the two studies that found no association between perceived bias and appointment attendance.^46,59 Two systematic reviews examining barriers to perinatal care access found perceived discrimination and disrespectful interaction to be a common deterrent for attending prenatal and postpartum appointments.^81,82 However, these reviews only included qualitative analysis, so the weight of the effect of perceived bias on attending perinatal appointments is still unknown. As perinatal health care attendance is important for the prevention of complications, future research and interventions might explore how to mitigate perceived bias to retain patient engagement.

Our review emphasizes the importance of patients’ perception of their care, their autonomy, and patient–provider relationships. Several quality measures frequently used in the studies we reviewed aligned with those associated with obstetric racism in the PREM-OB™ Scale, including perceived communication with health professionals and lack of patient consultation on intervention choices during the perinatal period.⁸³ This validated, psychometrically sound measure of patient-reported obstetric racism in perinatal care demonstrates how patient perspectives can be utilized to assess the impact of perceived bias on clinical encounters. Future research in this area should be conducted to create similar tools that could more specifically and comprehensively assess different possible aspects of perceived discrimination (such as economic or insurance based). Using validated tools in this area of research could further substantiate such research and allow for clinical conclusions to be drawn regarding the role of perceived bias and the utility of patient report in this regard.

How the qualitative and quantitative studies informed each other

Generally, qualitative studies were broader and explored the social and relational associations with perceived discrimination during the care encounter, whereas quantitative studies answered narrower research questions and attributed statistical significance to perceived bias. A benefit to qualitative research methods might be that participants are more comfortable discussing racism when given the social support to do so. In two focus groups, participants were initially found to be reluctant to discuss racism at the beginning of the group interviews, as the topic felt taboo, but through validation by other members of the group became more comfortable with the topic.^55,57 Evaluating studies using these two complementary forms of research avoided overreliance on statistics, captured subjective factors, and facilitated a more comprehensive understanding of the topic.

Persistent gaps in knowledge for future study to understand the role of perceived discrimination on perinatal outcomes

Research examining payment systems that affect provider time and care quality, along with implicit or explicit biases tied to Medicaid stereotypes, could inform educational efforts to enhance policies and practice. Another gap in our understanding of perceived bias is how it interconnects with the quality of care received and its impact on perinatal outcomes. While our research found that perceived discrimination influences patient experiences, the full extent to which these perceptions affect clinical decision-making, access to interventions, and health outcomes for birthing individuals and newborns is not known. Elucidating these connections would help to prioritize changes to health care that would improve outcomes.

Limitations

One limitation of this study was the potential for personal biases introduced by the authors during thematic analysis. As this process is integral to conducting a scoping review, we sought to mitigate bias by practicing reflexivity and maintaining self-awareness of our implicit biases based on our personal and professional backgrounds (as mentioned in the rigor section of the methods). Additionally, the selection of search terms may have shaped the scope of the findings, as variations in terms could have yielded different studies for inclusion. Search terms were determined following an initial broad survey, and when articles specifying demographics were identified, those demographics were incorporated into the search strategy. Although other common U.S. demographics, such as Native American populations, were included in the search, they were not represented in the studies reviewed for our topic of interest. As a result, conclusions should be drawn with caution. Despite these limitations, this review synthesizes research on perceived discrimination in perinatal care, offering insights for future researchers and clinicians to build upon.

Conclusions

This work contributes to existing efforts to elucidate the ways in which perceived clinician bias is associated with various metrics of perinatal care quality, evaluate how researchers are examining perceived bias, and help demonstrate the value of utilizing patients’ perception of bias/discrimination for its association with care quality. This review also highlights the importance of the relationship between provider and patient communication in the perinatal setting and how the perception of bias has a negative association with perceived care quality and patient agency. As such, our findings add to the growing body of research suggesting that interventions to reduce patient’s perceptions of bias by reducing provider implicit bias and improving communication strategies could improve health care quality and reduce maternal mortality. Although beyond the scope of this work, it is important to mention effective evidence-based strategies targeting interpersonal interactions such as shifting to a model of “relationship-based care”^84,85 and “cultural humility”⁸⁶; utilizing multilevel institutional approaches like the EQUIP model that targets bias through conversations, modules, workshops and violence informed care⁸⁷; and employing larger systemic approaches such as policy regulating implicit bias training in healthcare institutions and schools.^87,88 These could all have a positive impact on perinatal care quality and outcomes.

Future research that elucidates the relationship between quality metrics, implicit bias, and maternal health outcomes will allow us to systematically target aspects of care that are affected by the patient–provider relationship and contribute to worsened maternal health outcomes. This connection is critical in this moment as many researchers, activists, and birthing people grapple with understanding inequities in birth outcomes. By examining patient perspectives, continuing to fill research gaps, and considering multilevel interventions to improve care, we hold the promise of improving perinatal health outcomes for all birthing people.

Footnotes

Acknowledgments

The authors would like to acknowledge the Santa Monica College Interclub Council (ICC) Research Grant in Health Equity, Diversity and Inclusion to C.L.E. and R.E.T., and the Frances Lazda Endowed Chair in Women’s Cardiovascular Medicine to A.C.V. The authors would also like to acknowledge all the researchers and patients involved in all the studies that were used to compile this work.

Authors’ Contributions

R.E.T.: Conceptualization (equal), methodology (lead), investigation (lead), and writing—original draft (lead). C.L.E.: Conceptualization (equal), methodology (supporting), investigation (supporting), writing—original draft (supporting), and funding acquisition. A.C.V.: Writing—review and editing and clinical perspective and context.

Rigor Statement

The coauthors (C.E. and A.V.) and professors aided the first author (R.T.), a graduate student, in proficient scientific writing and synthesis, modeling of best practices, assistance with overcoming challenges in literature synthesis, and providing a supportive environment that fostered independence. This resulted in self-efficacy in academic growth, critical thinking skills, and a deep understanding of the topic area of this work, which facilitated professional commitment to the field.

Author Disclosure Statement

The authors have no conflicts of interest to disclose.

Funding Information

R.E.T. and C.L.E. received funds from the Santa Monica College Interclub Council (ICC) Research Grant in Health Equity, Diversity and Inclusion. A.C.V. received funds from the Frances Lazda Endowed Chair in Women’s Cardiovascular Medicine (endowed to A.C.V.).

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