Legislation Seeks to Reduce Black Maternal Mortality Through Implicit Bias Training

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OAKLAND – California Attorney General Rob Bonta, Assemblymember Lori Wilson (D-Suisun City), Assemblymember Dr. Akilah Weber (D-La Mesa), and members of the California Legislative Black Caucus, introduced AB 2319 aimed to reduce the alarming and disproportionate maternal mortality rate of Black women and other pregnant persons of color by ensuring successful implementation of Senate Bill 464 (SB 464) (Mitchell), the California Dignity in Pregnancy and Childbirth Act of 2019 (Act).

Today’s legislation builds on the California Department of Justice’s (DOJ) investigation to ensure and better equip healthcare facilities to come into full compliance with the Act, the findings of which were announced in DOJ’s Report on Healthcare Facilities and the California Dignity in Pregnancy and Childbirth Act. After DOJ began their investigation, providers’ rate of compliance improved dramatically from below 17% to over 81%. Although many facilities met the requirements of the Act, there is still work to be done to ensure full compliance.

“It is a tragic reality that race continues to be a factor in maternal health and infant mortality rates not just in California, but across this country,” said Attorney General Rob Bonta. “Together, we have made so much progress, and we must continue to address healthcare bias head-on. Today’s legislation does just that; it is designed to make transformational change in a system that has historically failed our mothers and babies, especially those of color. I want to thank the Legislative Black Caucus who worked tirelessly with us on this important legislation to create healthier outcomes for all Californians.”

“Black women in California face alarming disparities in maternal health outcomes. As a Black Mother and as Chair of the California Legislative Black Caucus, the fight to improve these outcomes is personal to me,” said Assemblywoman Lori D. Wilson (D–Suisun City). “I look forward to collaborating with our Attorney General Rob Bonta, Assemblymember Dr. Akilah Weber and other stakeholders to push this accountability measure across the finish line as we seek to make strides in improving Black maternal health outcomes throughout California.”

“The Black maternal morbidity and mortality rate cannot be explained by income or education levels alone. Data suggests what we know, what mothers have been brave enough to share, there is an embedded implicit bias in the maternal health care they receive. Providers ignore symptoms, ignore concerns to the horrible detriment of birthing women. So, sadly when uninformed care doesn’t result in death, it can still result in traumatic birthing experiences for both mother and child,” said Assemblymember Mia Bonta (D-Oakland), who is the newest Chair to the Assembly Health Committee. “California has been proactive in taking the steps to address this bias, but gaps in the process still exist. I am excited to partner with Assemblymember Wilson to address those shortcomings and ensure California is providing high quality healthcare for all women and birthing people so that everyone’s birthing experience concludes in a safe and healthy birth.”

“I stand in full support as a proud principal co-author of the collaborative efforts between the Attorney General and Assemblymember Wilson, Chair of the California Legislative Black Caucus, to fortify the implementation of SB 464, known as the California Dignity in Pregnancy and Childbirth Act,” said Assemblymember Mike A. Gipson (D-Carson). “This measure is fundamental in safeguarding the health and dignity of expectant mothers and their newborns. It is imperative that we redouble our efforts to uphold the principles of dignity and equity in pregnancy and childbirth. Together we can eradicate disparities in maternal care and promote equitable access to quality healthcare for all Californians.”

“California is failing its Black mothers. We have an obligation and moral duty to correct this grave injustice in California’s maternal healthcare. We owe it to our Black mothers to rectify the injustice causing alarming pregnancy-related deaths,” said Assemblymember Dr. Corey A. Jackson (D-Moreno Valley). “I am proud to support Attorney General Rob Bonta and Assemblymember Wilson for continuing this fight against bias and injustice in our healthcare settings. We must meet this moment and solve this issue immediately because lives are literally at stake.”

“The California Dignity in Pregnancy and Childbirth Act was driven by concerns over racial disparities in health care, and the black maternal morbidity and mortality crisis,” said Sandra Poole, Policy Advocate at Western Center on Law & Poverty. “The Act required evidence-based implicit bias training in the healthcare system to address this major factor in racial disparities.  Western Center on Law and Poverty applauds this legislation which would require full compliance with the Act, authorize penalties against non-compliant healthcare facilities, and ensure that healthcare systems are held accountable for providing care that is accessible to all Californians without structural inequities that are determinants of health outcomes.”

“California is a national leader when it comes to reproductive freedom, and we pride ourselves on having the lowest maternal mortality rate of any state in the country—but we still have tremendous work to do to ensure that all Black women and pregnant people in our state have access to quality, equitable, and unbiased care,” said Shannon Olivieri Hovis, Director at Reproductive Freedom for All California. “As a cosponsor of the original legislation requiring implicit bias training for perinatal providers, Reproductive Freedom for All California is proud to join this bill coalition, led by Attorney General Bonta and authored by Assemblymember Wilson and Dr. Weber. We are grateful to AG Bonta for his commitment to ensuring reproductive freedom for all.”

The United States has the highest maternal mortality rate in the developed world — a burden disproportionately borne by communities of color, especially Black women. In California in particular, Black women make up 5% of those pregnant but account for 21% of the total pregnancy-related deaths. This disparity exists across all income levels. Evidence suggests one key cause of this disparity is the implicit bias of healthcare providers. A provider’s level of bias, whether conscious or unconscious, can influence their interactions with patients and their diagnoses and treatment of the patient’s pain, and can undermine patients’ trust and engagement in care.

In August 2021, as part of an inquiry into whether providers were complying with the law, DOJ’s Healthcare Rights and Access Section (HRA) issued letters to California facilities requesting data on their implicit bias training of employees. Of the 242 responding facilities, 201 had not completed or even begun training staff until after receiving DOJ’s letters. Only 41 had begun training their employees in compliance with SB 464, but not a single employee had been fully trained. However, by July 8, 2022, when the investigation concluded, an average of 81.44% of the perinatal care staff in the 242 facilities had completed training.

DOJ’s investigation made clear that setting requirements as part of SB 464 was only the first step to ensuring the training of maternal care providers. Additional steps need to be taken to ensure hospitals and facilities comply with those requirements.

To help reach full compliance and thus help reduce maternal mortality AB 2319 would:

• Provide clarity on which facilities are mandated to administer anti-bias trainings and which employees need to be trained.
• Establish firm deadlines by which trainings must be completed to better guide compliance.
• Confer enforcement powers to the California Department of Public Health and the Attorney General, along with accountability measures.
• Require compliance data to be posted online so the public is made aware of which facilities have provided anti-bias trainings and which have not.
• Establish administrative penalties for noncompliant facilities.
• Add inclusive language to account for nonbinary people and men of transgender experience who also carry children and give birth.

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