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

BACKGROUND: Person-centered maternity care (PCMC) has become a priority in the global health discourse on 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 inequitable 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 negative 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 0.71 (SD = 0.43), indicating a significant bias in associating positive characteristics with high SES women and negative characteristics with low SES women. Providers with higher education had significantly lower explicit bias scores on the low SES vignette than those with less education. 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.