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

Kelly M. Bower, Briana Kramer, Nicole Warren, Saifuddin Ahmed, Jennifer Callaghan-Koru, Elizabeth Stierman, Cheri Wilson, Shari Lawson, Andreea A. Creanga

Research output: Contribution to journalArticlepeer-review


BACKGROUND: Implicit bias among maternal healthcare professionals contributes to disrespectful care and racial and ethnic disparities in patient outcomes, and there is growing consensus that implicit bias training 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 psychometrically valid instrument for use in the evaluation of implicit bias training. OBJECTIVE: This study aimed to develop a valid and reliable instrument 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 validation 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 Mitigation Practice subscale (Cronbach's alpha, 0.82), and a 7-item Bias Mitigation Self-Efficacy subscale (Cronbach's alpha, 0.81). Validation of the Bias Awareness and Bias Mitigation Practice subscales in phase 3 demonstrated 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 measuring awareness and mitigation of bias among maternal healthcare professionals. It can be used to evaluate implicit bias training and other bias mitigation interventions in maternal healthcare settings.

Original languageEnglish (US)
Article number100872
JournalAmerican Journal of Obstetrics and Gynecology MFM
Issue number4
StatePublished - Apr 2023


  • birth equity
  • disparities
  • health equity
  • implicit bias
  • inequity
  • maternal health
  • psychometrics
  • quality improvement
  • reliability
  • validity

ASJC Scopus subject areas

  • Obstetrics and Gynecology


Dive into the research topics of 'Development of an instrument to measure awareness and mitigation of bias in maternal healthcare'. Together they form a unique fingerprint.

Cite this