Attorney General Bonta Announces Results of Investigation into Anti-Bias Training for Pregnancy Care Providers

California law requires health facilities to train staff in overcoming unconscious racial biases that could harm pregnant patients of color

After DOJ investigation began, providers’ rate of compliance improved dramatically from below 17% to over 81%

LOS ANGELES — Attorney General Rob Bonta today announced the results of a California Department of Justice (DOJ) investigation into anti-implicit bias training for perinatal care providers — health professionals who provide care for pregnant patients. Studies, including a recent one by the California Department of Public Health, have found that women of color, and in particular Black women, die of pregnancy-related complications at much higher rates than White women in California. To help address these stark racial disparities, the California Dignity in Pregnancy and Childbirth Act (SB 464) was passed in 2019. The law requires health facilities to train perinatal care providers in recognizing and overcoming their own implicit or unconscious racial biases and prejudices that could negatively impact the quality of care — and even endanger the lives of — pregnant patients of color. In August 2021, DOJ initiated an investigation to determine compliance with the law. At that time, fewer than 17% of responding providers had even begun training their employees and not a single employee had been fully trained. By the time DOJ’s investigation and outreach efforts concluded 10 months later, the training completion rate had shot up to more than 81%. These and other findings are detailed in the Report on Healthcare Facilities and the California Dignity in Pregnancy and Childbirth Act released today.

“The disparity in maternal death rates in California reflects the deep and shameful racial inequities in our healthcare system,” said Attorney General Bonta. “In California, people of color, particularly Black women, continue to die at three to four times the rate of White women. This is unacceptable. With today’s report, the California Department of Justice has taken an important step forward in addressing this issue by successfully building upon the California Dignity in Pregnancy and Childbirth Act. When it comes to healthcare, bias — even when it’s implicit — can be the difference between life and death for a patient. At DOJ, we will continue to fight for equity in healthcare and look out for the health and future of all Californians.”

“Implicit bias is one of the silent architects contributing to the health inequities experienced by Black moms and babies," said Black Women for Wellness Maternal and Infant Health Program Coordinator Gabrielle Brown. "In Black maternal and infant health, it is within our power to commit to deconstruct the barriers it builds and create a world where every mother and child receive care that knows no bias. Our commitment is to impact not only today, it is to our children, grandchildren and future generations so they have the best we have to offer in this society.”

“As a Black woman, a mother, a legislator, and as a board-certified OBYGN, this topic of implicit bias and black maternal mortality is both personally and professionally important to me,” said Assemblymember Dr. Akilah Weber. “Within our healthcare system, implicit bias leads to certain actions or inactions from medical providers who are not properly trained to identify their own biases, which then leads to providing disparate medical care causing some groups to have better outcomes than others. Thank you, Attorney General Rob Bonta, for your authentic commitment to addressing this issue. I look forward to working together on the recommendations to strengthen current policies.”

“It is unconscionable that the United States, the wealthiest country in the world, has the highest maternal mortality rate of any other developed nation," said Congresswoman Sydney Kamlager-Dove. "Today, I am proud to stand with Attorney General Bonta and other maternal mortality advocates to shed a brighter light on the steps we need to take to ensure better maternal health outcomes for women in California and across our country. All mothers, specifically mothers of color, deserve care from providers they can trust. I have been glad to lead efforts to mandate implicit bias training in the medical profession. Just this year in Congress, I became a cosponsor for the Momnibus Act, a legislative package aimed at preventing Black maternal mortality and implementing safeguards to improve maternal health. I will always support critical legislation and efforts that ensure the health of all mothers, mothers-to-be, and our children.”

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. 

SB 464 is an effort to address the racial disparity in maternal morbidity rates by changing the way that healthcare providers recognize and overcome their own implicit bias when treating pregnancy. The law requires hospitals, alternative birth centers and primary care clinics to conduct evidence-based implicit bias training for all health professionals who provide care during a patient’s pregnancy, childbirth, and immediate postpartum period. 

In August 2021, as part of an inquiry into whether providers were complying with the law, DOJ’s Healthcare Rights and Access Section issued letters to California facilities requesting data on their implicit bias training of employees. Of the 242 responding facilities, 201 had not completed, and in some cases had not 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 improve compliance, DOJ suggests providing:

1. Clarity on which employees need to be trained.
2. Firm deadlines by which trainings must be completed.
3. Clear enforcement mechanisms for one or more state agencies to enforce SB 464.
4. Consequences for non-compliant hospitals and facilities.
5. Inclusive language to account for nonbinary people and men of transgender experience who also carry children and give birth.

Attorney General Bonta will work with the California Legislature on future legislation to strengthen SB 464 in accordance with these recommendations.  

DOJ’s Report on Healthcare Facilities and the California Dignity in Pregnancy and Childbirth Act can be found here.