The way people are treated in healthcare settings reflects larger societal norms and behaviors. Disrespect thrives where it is tolerated, and individual biases reinforce patterns of abuse. In societies where differential treatment based on socio-economic status is normal, providers may unconsciously treat poor women with disrespect.

Bixby member Patience Afulani conducted a study with maternity care providers in western Kenya to understand provider implicit and explicit bias and how that may contribute to disparities in care.

They found evidence of both explicit and implicit socioeconomic bias among maternity care providers. Those biases may contribute to disparities in care in varied and sometimes contradictory ways. The providers were more likely to agree that low socioeconomic status women aren’t likely to expect providers to introduce themselves and aren’t likely to understand explanations, disincentivizing these critical aspects of person-centered care. They think higher status women are more likely to exaggerate their pain and to sue them if something goes wrong. They thought these women were seeking special treatment and would be more difficult to please. As one provider said, “Those who are poor are easier to attend to because even if you tell them anything, they get satisfied and follow instructions, but the rich people don’t appreciate.”

They also heard concerning ideas that conflict with the autonomy and dignity at the heart of person-centered care. Close to half of providers agreed that a woman coming to a facility means that she has consented to all examinations and treatments. About 1/3 agreed that women are likely to be uncooperative when it’s time to push and will need to be physically restrained.

Potential sources of implicit and explicit bias included:

Attraction based on women’s appearance. When women appeared well-dressed and clean, they were treated better than those who were dirty and unkempt.
Assumptions about who is knowledgeable, more likely to understand and be cooperative. Providers perceived more educated women as having better understanding, hence being easier to deal with.
Expectations, ability to advocate for oneself and accountability. Women of higher status were perceived as having higher expectations for care and the ability to command higher-quality care.
Ability to provide financially for their care. Women able to pay for needed supplies, tests and medications also received more timely care.

Better care did not necessarily imply providers’ preference for a patient. They found complex interactions between factors that led to differential care. Providers’ preferences for women who could understand their instructions sometimes conflicted with their preference for women to be cooperative.

Making lasting change will require a shift in thinking about what makes a good patient-provider encounter. Providers need to move from a model where a passive patient is preferred to embrace a model where all women are encouraged to be active participants in their care. This reorientation is essential to provide the kind of quality, dignified maternity care that can save lives.