The United States has higher rates of maternal morbidity and mortality than peer countries, a burden disproportionately carried by Black women (Admon et al., 2018Admon L.K. Winkelman T.N.A. Zivin K. Terplan M. Mhyre J.M. Dalton V.K. Racial and ethnic disparities in the incidence of severe maternal morbidity in the United States, 2012-2015.Obstetrics and Gynecology. 2018; 132: 1158-1166Crossref PubMed Scopus (90) Google Scholar; Petersen et al., 2019Petersen E.E. Davis N.L. Goodman D. Cox S. Syverson C. Seed K. Barfield W. Racial/Ethnic Disparities in Pregnancy-Related Deaths - United States, 2007-2016.MMWR Morbidity and Mortality Weekly Reports. 2019; 68: 762-765Crossref PubMed Scopus (0) Google Scholar; World Health Organization, 2015World Health Organization Trends in maternal mortality: 1990-2015. World Health Organization.2015Google Scholar). Numerous factors are thought to contribute, including a high chronic disease burden and poor-quality care (Admon et al., 2018Admon L.K. Winkelman T.N.A. Zivin K. Terplan M. Mhyre J.M. Dalton V.K. Racial and ethnic disparities in the incidence of severe maternal morbidity in the United States, 2012-2015.Obstetrics and Gynecology. 2018; 132: 1158-1166Crossref PubMed Scopus (90) Google Scholar; Howell et al., 2016Howell E.A. Egorova N. Balbierz A. Zeitlin J. Hebert P.L. Black-white differences in severe maternal morbidity and site of care.American Journal of Obstetrics and Gynecology. 2016; 214: 122.e1-122.e7Abstract Full Text Full Text PDF Scopus (130) Google Scholar). Differential outcomes persist, however, even when pregnant Black women obtain care in high-quality hospitals and when controlling for comorbidities (Howell et al., 2016Howell E.A. Egorova N. Balbierz A. Zeitlin J. Hebert P.L. Black-white differences in severe maternal morbidity and site of care.American Journal of Obstetrics and Gynecology. 2016; 214: 122.e1-122.e7Abstract Full Text Full Text PDF Scopus (130) Google Scholar). Thus, in addition to addressing structural racism, health systems must ensure that individual clinical encounters are free of bias (Howell et al., 2018Howell E.A. Brown H. Brumley J. Bryant A.S. Caughey A.B. Cornell A.M. Grobman W.A. Reduction of peripartum racial and ethnic disparities: A conceptual framework and maternal safety consensus bundle.Obstetrics and Gynecology. 2018; 131: 770-782Crossref PubMed Scopus (53) Google Scholar). Clinicians' implicit bias—unconscious attitudes and beliefs that impact behaviors like body language, tone of voice, receptivity, or decision-making—affects treatment decisions and outcomes (Hall et al., 2015Hall W.J. Chapman M.V. Lee K.M. Merino Y.M. Thomas T.W. Payne B.K. Coyne-Beasley T. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review.American Journal of Public Health. 2015; 105: e60-e76Crossref PubMed Scopus (778) Google Scholar; Howell et al., 2018Howell E.A. Brown H. Brumley J. Bryant A.S. Caughey A.B. Cornell A.M. Grobman W.A. Reduction of peripartum racial and ethnic disparities: A conceptual framework and maternal safety consensus bundle.Obstetrics and Gynecology. 2018; 131: 770-782Crossref PubMed Scopus (53) Google Scholar). In obstetrics, bias may be experienced throughout pregnancy and the postpartum period. For instance, Hispanic women report lower trust in their clinician than other groups, and Black women report worse postpartum pain management (Declercq et al., 2013Declercq E.R. Sakala C. Corry M.P. Applebaum S. Herrlich A. Listening to mothers III: Pregnancy and birth. Childbirth Connection, New York City, NY2013Google Scholar). One in 10 Black mothers reports they were “treated poorly” because of their identity when hospitalized compared to just 3 in 100 White mothers. Implicit bias can also be rooted in seemingly “evidence-based” practice. Until a recent revision, the widely used Trial of Labor After Cesarean (TOLAC) calculator stratified patients by race and ethnicity based on an observational, not pathophysiologic, basis (Grobman et al., 2007Grobman W.A. Lai Y. Landon M.B. Spong C.Y. Leveno K.J. Rouse D.J. Human Development Maternal-Fetal Medicine Units N. Development of a nomogram for prediction of vaginal birth after cesarean delivery.Obstetrics and Gynecology. 2007; 109: 806-812Crossref PubMed Scopus (285) Google Scholar, Grobman et al., 2021Grobman W.A. Sandoval G. Rice M.M. Bailit J.L. Chauhan S.P. Costantine M.M. Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network Prediction of vaginal birth after cesarean delivery in term gestations: A calculator without race and ethnicity.American Journal of Obstetrics and Gynecology. 2021; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (16) Google Scholar). Commentators note that the lower rates of “successful” TOLAC for Black women in the original validation study may be due to circular logic stemming from biased decision-making by providers, that is, sending Black laboring women to the operating room sooner than their White peers (Vyas et al., 2019Vyas D.A. Jones D.S. Meadows A.R. Diouf K. Nour N.M. Schantz-Dunn J. Challenging the use of race in the vaginal birth after cesarean section calculator.Womens Health Issues. 2019; 29: 201-204Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar). Similarly, race-based correction factors for anemia may bias maternity care clinicians, leading to lower treatment rates of iron-deficiency anemia and explaining the disproportionately high rates of blood transfusions at birth for Black women (Igbinosa et al., 2020Igbinosa I. Leonard S.A. Butwick A.J. Lyell D.J. Antepartum anemia and racial/ethnic disparities in blood transfusion in California.American Journal of Obstetrics and Gynecology. 2020; 222Abstract Full Text Full Text PDF Google Scholar). Many groups, including the Alliance for Innovation in Maternal Health (AIM), the American College of Obstetricians and Gynecologists (ACOG), and the Society of Maternal Fetal Medicine, have made it a priority to reduce maternity care clinicians' implicit bias (Council on Patient Safety in Women’s HealthcareCouncil on Patient Safety in Women’s Healthcare What is AIM?.https://safehealthcareforeverywoman.org/aim-program/Date accessed: July 19, 2021Google Scholar; Racial and Ethnic Disparities in Obstetrics and Gynecology. ACOG Committee Opinion No. 649, 2015Racial and Ethnic Disparities in Obstetrics and Gynecology. ACOG Committee Opinion No. 649.Obstetrics and Gynecology. 2015; 126: e130-e134Crossref PubMed Scopus (10) Google Scholar; Racial disparities in health outcomes, 2017Racial disparities in health outcomes.https://s3.amazonaws.com/cdn.smfm.org/media/1108/Racial_Disparities_-_Jan_2017.pdfDate: 2017Date accessed: May 17, 2020Google Scholar). Although implicit bias is widely recognized as a threat to quality obstetric care—and some states, such as California, Illinois, and Michigan, now mandate that clinicians receive implicit bias training—there is little evidence-based guidance for health systems and clinicians on effective interventions (California Dignity in Pregnancy and Childbirth Act, 2020California Dignity in Pregnancy and Childbirth Act, SB 464, Senate. 2020Google Scholar; Illinois Health Care and Human Service Reform Act, 2021Illinois Health Care and Human Service Reform Act, Pub. L. No. 102-0004, (2021).Google Scholar; Whitmer, 2020Whitmer G. Executive Directive 2020-7: Improving equity in the delivery of health care.2020Google Scholar). For example, the AIM bundle to reduce racial disparities does not provide specific guidance (Council on Patient Safety in Women’s Healthcare, 2016Council on Patient Safety in Women’s Healthcare Reduction of peripartum racial/ethnic disparities.https://safehealthcareforeverywoman.org/patient-safety-bundles/reduction-of-peripartum-racialethnic-disparities/Date: 2016Date accessed: July 17, 2021Google Scholar). Even when a program is implemented, most existing implicit bias interventions are found to be ineffective when rigorously evaluated (FitzGerald et al., 2019FitzGerald C. Martin A. Berner D. Hurst S. Interventions designed to reduce implicit prejudices and implicit stereotypes in real world contexts: A systematic review.BMC Psychology. 2019; 7: 29Crossref PubMed Scopus (107) Google Scholar). In fact, all but one evaluated intervention lack durability beyond seconds to minutes (Lai et al., 2016Lai C.K. Skinner A.L. Cooley E. Murrar S. Brauer M. Devos T. Nosek B.A. Reducing implicit racial preferences: II. Intervention effectiveness across time.Journal of Experimental Psychology. General. 2016; 145: 1001-1016Crossref PubMed Scopus (256) Google Scholar). The field is further challenged by a lack of standardized measures of bias (FitzGerald et al., 2019FitzGerald C. Martin A. Berner D. Hurst S. Interventions designed to reduce implicit prejudices and implicit stereotypes in real world contexts: A systematic review.BMC Psychology. 2019; 7: 29Crossref PubMed Scopus (107) Google Scholar). Despite these challenges, health systems have an ethical, and sometimes legal, obligation to act because of the urgent stakes for pregnant Black women. We compiled core concepts present in the literature that can be used to design implicit bias interventions. We propose that three domains are critical: education and self-awareness, communication skills, and cognitive reframing (Figure 1A). We also strongly advocate that patient advisory boards or focus groups be central to the development process and engaged early as collaborators in all domains. Interventions should include all care team members, including physicians, midwives, nurses, social workers, front desk staff, and custodial staff. Although efficacy data within each domain are suboptimal, interventions may have a greater effect when combined. This notion is supported by other obstetric safety and quality improvement initiatives that are enhanced by multidimensional approaches to change (Pettker and Grobman, 2015Pettker C.M. Grobman W.A. Obstetric Safety and Quality.Obstetrics and Gynecology. 2015; 126: 196-206Crossref PubMed Scopus (38) Google Scholar). Because specific literature on bias intervention in obstetrics is limited, we provide a mixture of evidence from within and outside of obstetrics in this commentary (Howell et al., 2018Howell E.A. Brown H. Brumley J. Bryant A.S. Caughey A.B. Cornell A.M. Grobman W.A. Reduction of peripartum racial and ethnic disparities: A conceptual framework and maternal safety consensus bundle.Obstetrics and Gynecology. 2018; 131: 770-782Crossref PubMed Scopus (53) Google Scholar). Precise definitions of implicit bias and increased awareness of one's bias provide a common foundation for change. Educational initiatives should also incorporate cognitive science such as classical conditioning to contextualize interventions (Kirwan Institute for the Study of Race and Ethnicity and Ohio State University, 2018Kirwan Institute for the Study of Race and Ethnicity Ohio State University Implicit bias module series.http://kirwaninstitute.osu.edu/implicit-bias-training/Date: 2018Date accessed: December 10, 2019Google Scholar; Sukhera and Watling, 2018Sukhera J. Watling C. A framework for integrating implicit bias recognition into health professions education.Academic Medicine. 2018; 93: 35-40Crossref PubMed Scopus (75) Google Scholar). Reflective self-assessment tools such as the publicly accessible Implicit Associations Test of Project Implicit can also help participants to understand how implicit bias operates on an individual level (Greenwald et al., 1998Greenwald A.G. McGhee D.E. Schwartz J.L. Measuring individual differences in implicit cognition: the implicit association test.Journal of Personaluty and Social Psychology. 1998; 74: 1464-1480Crossref PubMed Scopus (6927) Google Scholar; Project Implicit, 2011Project Implicit Harvard University.https://implicit.harvard.edu/implicit/index.jspDate: 2011Date accessed: July 3, 2021Google Scholar). Although the Implicit Associations Test does not predict discriminatory behavior, it has usefulness as a discussion starter (Sukhera et al., 2019bSukhera J. Wodzinski M. Rehman M. Gonzalez C.M. The Implicit Association Test in health professions education: A meta-narrative review.Perspectives on Medical Educcation. 2019; 8: 267-275Crossref PubMed Scopus (20) Google Scholar). Given that some research has demonstrated resistant responses to implicit bias education, expert facilitators can create a nonjudgmental learning culture that promotes receptivity of participants (Pendry et al., 2007Pendry L.F. Driscoll D.M. Field S.C.T. Diversity training: Putting theory into practice.Journal of Occupational and Organizational Psychology. 2007; 80: 27-50Crossref Scopus (137) Google Scholar; Sukhera and Watling, 2018Sukhera J. Watling C. A framework for integrating implicit bias recognition into health professions education.Academic Medicine. 2018; 93: 35-40Crossref PubMed Scopus (75) Google Scholar; Sukhera et al., 2019bSukhera J. Wodzinski M. Rehman M. Gonzalez C.M. The Implicit Association Test in health professions education: A meta-narrative review.Perspectives on Medical Educcation. 2019; 8: 267-275Crossref PubMed Scopus (20) Google Scholar). Online modules, such as the Kirwan Institute Implicit Bias Module Series, have also been developed for asynchronous learning, easing distribution (Kirwan Institute for the Study of Race and Ethnicity and Ohio State University, 2018Kirwan Institute for the Study of Race and Ethnicity Ohio State University Implicit bias module series.http://kirwaninstitute.osu.edu/implicit-bias-training/Date: 2018Date accessed: December 10, 2019Google Scholar). Grand rounds and lecture series can also be used for sharing educational resources that promote self-awareness. •Distribute an educational module for developing common definitions that integrates cognitive science. Consider asynchronous modules, lecture series, or didactic sessions to decrease barriers to participation.•Use the Implicit Associations Test to help participants understand implicit bias and as a tool for self-reflection.•Use expert facilitators who can help participants remain receptive to emotionally challenging content. Communication skills are important as they may drive or mitigate the impact of implicit bias (Braveman et al., 2017Braveman P. Heck K. Egerter S. Dominguez T.P. Rinki C. Marchi K.S. Curtis M. Worry about racial discrimination: A missing piece of the puzzle of Black-White disparities in preterm birth?.PLoS One. 2017; 12: e0186151Crossref PubMed Scopus (53) Google Scholar; Hagiwara et al., 2019Hagiwara N. Elston Lafata J. Mezuk B. Vrana S.R. Fetters M.D. Detecting implicit racial bias in provider communication behaviors to reduce disparities in healthcare: Challenges, solutions, and future directions for provider communication training.Patient Education and Counseling. 2019; 102: 1738-1743Crossref PubMed Scopus (25) Google Scholar). This point is especially true in obstetrics care, where patients and clinicians meet frequently over the course of a pregnancy and discuss complex anticipatory guidance. Women of color identify poor information sharing during pregnancy as a locus of constrained autonomy (Altman et al., 2019Altman M.R. Oseguera T. McLemore M.R. Kantrowitz-Gordon I. Franck L.S. Lyndon A. Information and power: Women of color's experiences interacting with health care providers in pregnancy and birth.Socail Science and Medicine. 2019; 238: 112491Crossref PubMed Scopus (66) Google Scholar). For instance, they describe receiving misleading information meant to influence their decisions and do not feel they are a part of the “the team.” This paternalistic approach experienced by pregnant women of color is in stark contrast with ethical standards of care (Ethical decision making in obstetrics and gynecology, 2007Ethical decision making in obstetrics and gynecology. ACOG Committee Opinion No. 390.Obstetrics and Gynecology. 2007; 110: 1479-1487Crossref PubMed Scopus (49) Google Scholar). Antecedents of perceived discrimination include curt responses, lack of eye contact and smiling, dismissiveness, and impatience (Tajeu et al., 2015Tajeu G.S. Cherrington A.L. Andreae L. Prince C. Holt C.L. Halanych J.H. "We'll get to you when we get to you": Exploring potential contributions of health care staff behaviors to patient perceptions of discrimination and satisfaction.American Journal of Public Health. 2015; 105: 2076-2082Crossref PubMed Scopus (34) Google Scholar). Among obstetrics patients of color, relationship building and sharing information about care, such as treatment options, can reduce perceived discrimination (Altman et al., 2019Altman M.R. Oseguera T. McLemore M.R. Kantrowitz-Gordon I. Franck L.S. Lyndon A. Information and power: Women of color's experiences interacting with health care providers in pregnancy and birth.Socail Science and Medicine. 2019; 238: 112491Crossref PubMed Scopus (66) Google Scholar). Importantly, acknowledging perceived bias can restore clinical relationships (Gonzalez et al., 2018Gonzalez C.M. Deno M.L. Kintzer E. Marantz P.R. Lypson M.L. McKee M.D. Patient perspectives on racial and ethnic implicit bias in clinical encounters: Implications for curriculum development.Patient Education and Counseling. 2018; 101: 1669-1675Crossref PubMed Scopus (29) Google Scholar). In addition to improving the patient experience, effective communication can mitigate the roots of bias itself. Positive contact between people of different identities can reduce prejudice via empathy, decreased anxiety, and increased perspective-taking (imagining the viewpoint of a member of a stereotyped group) (Devine et al., 2012Devine P.G. Forscher P.S. Austin A.J. Cox W.T. Long-term reduction in implicit race bias: A prejudice habit-breaking intervention.Journal of Experimetnal and Social Psychology. 2012; 48: 1267-1278Crossref PubMed Scopus (546) Google Scholar; Pettigrew and Tropp, 2008Pettigrew T.F. Tropp L.R. How does intergroup contact reduce prejudice? Meta-analytic tests of three mediators.European Journal of Social Psychology. 2008; 38: 922-934Crossref Scopus (1361) Google Scholar; van Ryn et al., 2015van Ryn M. Hardeman R. Phelan S.M. Burgess D.J. Dovidio J.F. Herrin J. Przedworski J.M. Medical school experiences associated with change in implicit racial bias among 3547 students: A medical student CHANGES study report.Journal of General Internal Medicine. 2015; 30: 1748-1756Crossref PubMed Scopus (151) Google Scholar). Key principles of improved clinician communication such as demonstrating empathy and limiting interruptions should be integrated into all clinical encounters (Figure 1B) (Effective patient-physician communication, 2014Effective patient-physician communication. ACOG Committee Opinion No. 587.Obstetrics and Gynecology. 2014; 123: 389-393Crossref PubMed Scopus (8) Google Scholar; Frankel and Sherman, 2015Frankel R.M. Sherman H.B. The secret of the care of the patient is in knowing and applying the evidence about effective clinical communication.Oral Diseases. 2015; 21: 919-926Crossref PubMed Scopus (8) Google Scholar; Thom, 2001Thom D.H. Physician behaviors that predict patient trust.Journal of Family Practice. 2001; 50: 323-328PubMed Google Scholar). Shared decision-making—that is, making treatment choices by giving patients information and eliciting their priorities—can also help (Effective patient-physician communication, 2014Effective patient-physician communication. ACOG Committee Opinion No. 587.Obstetrics and Gynecology. 2014; 123: 389-393Crossref PubMed Scopus (8) Google Scholar). Rapport building can be enhanced by connecting on a “social level.” Health systems and individual clinics can provide communications training for clinicians and staff, integrate communications best practices into chart reminders, and prioritize communications skills in hiring and promotion (Casebeer et al., 1999Casebeer L.L. Klapow J.C. Centor R.M. Stafford M.A. Renkl L.A. Mallinger A.P. Kristofco R.E. An intervention to increase physicians' use of adherence-enhancing strategies in managing hypercholesterolemic patients.Academic Medicine. 1999; 74: 1334-1339Crossref PubMed Scopus (19) Google Scholar; Effective patient-physician communication, 2014Effective patient-physician communication. ACOG Committee Opinion No. 587.Obstetrics and Gynecology. 2014; 123: 389-393Crossref PubMed Scopus (8) Google Scholar; Zolnierek and Dimatteo, 2009Zolnierek K.B. Dimatteo M.R. Physician communication and patient adherence to treatment: A meta-analysis.Medical Care. 2009; 47: 826-834Crossref PubMed Scopus (1348) Google Scholar). •Improve patient–clinician communication by using best practices (Figure 1B). This practice may require training as part of undergraduate and graduate medical education, and clinician and staff professional development curricula.•Acknowledge perceived bias to help restore a clinical relationship (Gonzalez et al., 2018Gonzalez C.M. Deno M.L. Kintzer E. Marantz P.R. Lypson M.L. McKee M.D. Patient perspectives on racial and ethnic implicit bias in clinical encounters: Implications for curriculum development.Patient Education and Counseling. 2018; 101: 1669-1675Crossref PubMed Scopus (29) Google Scholar).•Prioritize communications best practices in chart reminders and hiring and promotion decisions. Given that implicit bias is an involuntary process, interventions must act on the underlying cognition. This point is important in obstetrics because of clinicians' reliance on cognitive frameworks for decision-making, especially when confronted with high-acuity conditions such as childbirth complications. For instance, Black women are more likely than White women to undergo cesarean section for nonreassuring fetal heart tones (Washington et al., 2012Washington S. Caughey A.B. Cheng Y.W. Bryant A.S. Racial and ethnic differences in indication for primary cesarean delivery at term: Experience at one U.S.Institution. Birth. 2012; 39: 128-134Crossref PubMed Scopus (40) Google Scholar). Because the interpretation of fetal heart rate tracings allows clinician subjectivity and has poor specificity for neonatal outcomes, this practice provides ample opportunity for clinician bias to impact counseling on timing and indication for cesarean birth (Ponsiglione et al., 2021Ponsiglione A.M. Cosentino C. Cesarelli G. Amato F. Romano M. A comprehensive review of techniques for processing and analyzing fetal heart rate signals.Sensors (Basel). 2021; 21Crossref PubMed Scopus (8) Google Scholar). Discredited theories about racial differences in pelvic floor anatomy and the TOLAC calculator's prior use of race in predicting outcomes may also have shaped how clinicians counsel patients who are considering vaginal birth after cesarean (Vyas et al., 2019Vyas D.A. Jones D.S. Meadows A.R. Diouf K. Nour N.M. Schantz-Dunn J. Challenging the use of race in the vaginal birth after cesarean section calculator.Womens Health Issues. 2019; 29: 201-204Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar). Because both of these concepts have been standard teachings in obstetrics education until recently, correcting for them will require a concerted effort by each individual clinician. Only one intervention—a “habit-breaking” model—has been demonstrated to have long-term efficacy in decreasing implicit bias (Devine, 1989Devine P.G. Stereotypes and prejudice: Their automatic and controlled components.Journal of Personality and Social Psychology. 1989; 56: 5-18Crossref Scopus (3743) Google Scholar; FitzGerald et al., 2019FitzGerald C. Martin A. Berner D. Hurst S. Interventions designed to reduce implicit prejudices and implicit stereotypes in real world contexts: A systematic review.BMC Psychology. 2019; 7: 29Crossref PubMed Scopus (107) Google Scholar; Forscher et al., 2017Forscher P.S. Mitamura C. Dix E.L. Cox W.T.L. Devine P.G. Breaking the prejudice habit: Mechanisms, timecourse, and longevity.Journal of Experimetnal and Social Psychology. 2017; 72: 133-146Crossref PubMed Scopus (72) Google Scholar). Users of this model recognize when bias may occur and then actively reframe their thoughts through stereotype replacement, counter-stereotypic imaging, individuation, perspective-taking, and increasing opportunities for intergroup contact (Table 1) (Devine et al., 2012Devine P.G. Forscher P.S. Austin A.J. Cox W.T. Long-term reduction in implicit race bias: A prejudice habit-breaking intervention.Journal of Experimetnal and Social Psychology. 2012; 48: 1267-1278Crossref PubMed Scopus (546) Google Scholar). It has been implemented in medicine, albeit not in an obstetrics context. One academic medical center conducted a 2.5-hour workshop that decreased gender bias in hiring 3 months after the intervention (Carnes et al., 2015Carnes M. Devine P.G. Baier Manwell L. Byars-Winston A. Fine E. Ford C.E. Sheridan J. The effect of an intervention to break the gender bias habit for faculty at one institution: a cluster randomized, controlled trial.Academic Medicine. 2015; 90: 221-230Crossref PubMed Scopus (285) Google Scholar). Cognitive reframing can be supported and enhanced with the following three strategies. First, expert facilitators may be used to address clinicians' negative reactions, vulnerability, defensiveness, and avoidance (Cox and Devine, 2019Cox W.T.L. Devine P.G. The prejudice habit-breaking intervention.in: Mallett R.K. Monteith M.J. Confronting prejudice and discrimination: The science of changing minds and behaviors. Academic Press, New York2019: 249-274Crossref Scopus (10) Google Scholar; Pendry et al., 2007Pendry L.F. Driscoll D.M. Field S.C.T. Diversity training: Putting theory into practice.Journal of Occupational and Organizational Psychology. 2007; 80: 27-50Crossref Scopus (137) Google Scholar). Next, integrating a patient's situational, economic, and social circumstances (e.g., housing insecurity) into morbidity and mortality rounds will support reframing clinical decisions (Cheryan et al., 2009Cheryan S. Plaut V.C. Davies P.G. Steele C.M. Ambient belonging: How stereotypical cues impact gender participation in computer science.Journal of Personality and Social Psychology. 2009; 97: 1045-1060Crossref PubMed Scopus (639) Google Scholar; Kawakami et al., 2000Kawakami K. Dovidio J.F. Moll J. Hermsen S. Russin A. Just say no (to stereotyping): Effects of training in the negation of stereotypic associations on stereotype activation.Journal of Personality and Social Psychology. 2000; 78: 871-888Crossref PubMed Scopus (385) Google Scholar). Finally, ancillary strategies such as reducing the use of pejorative or depersonalizing language (i.e., “a person with substance use disorder” instead of “addict”) and the use of diverse visual materials for marketing or patient education can reframe how implicit biases impact clinical decision-making.Table 1Definition of Terms for Habit Breaking Model to Decrease Implicit BiasAdapted from Devine et al., 2012Devine P.G. Forscher P.S. Austin A.J. Cox W.T. Long-term reduction in implicit race bias: A prejudice habit-breaking intervention.Journal of Experimetnal and Social Psychology. 2012; 48: 1267-1278Crossref PubMed Scopus (546) Google Scholar.TermDefinitionStereotype replacementRecognize a stereotype, label it as such, and replace it with a nonstereotypic responseCounter-stereotypic imagingThink of a person from the stereotyped group who does not exemplify the stereotypeIndividuationFocus on individual characteristics of a member of the stereotyped group, not their membership in that groupPerspective-takingImagine the perspective of a member of a stereotyped groupIncreased contactInterpersonal exposure to members of stereotyped groups Open table in a new tab •Develop trainings using the cognitive science of habit breaking (Table 1). Use expert facilitation to contextualize trainings, create a safe space for growth, and mitigate negative reactions from participants.•Integrate perspective-taking and social determinants of health into morbidity and mortality rounds.•Support intensive interventions with organizational-culture change, such as integrating diverse images in marketing and patient education and decreasing the use of pejorative or depersonalizing language. Patient engagement is foundational to developing and implementing initiatives to address implicit bias because it centralizes patients’ expertise. Early input can ensure that patients meaningfully inform the intervention and that they are viewed as collaborators rather than tokenized (Patient-Centered Outcomes Research InstitutePatient-Centered Outcomes Research Institute Building effective multi-stakeholder research teams.https://research-teams.pcori.org/Date accessed: August 17, 2021Google Scholar). Once involved, patients can define target groups for the intervention, types of bias, and core strategies for mitigation within each domain (McLemore et al., 2018McLemore M.R. Altman M.R. Cooper N. Williams S. Rand L. Franck L. Health care experiences of pregnant, birthing and postnatal women of color at risk for preterm birth.Socail Science and Medicine. 2018; 201: 127-135Crossref PubMed Scopus (113) Google Scholar; Salm Ward et al., 2013Salm Ward T.C. Mazul M. Ngui E.M. Bridgewater F.D. Harley A.E. "You learn to go last": Perceptions of prenatal care experiences among African-American women with limited incomes.Maternal and Child Health Journal. 2013; 17: 1753-1759Crossref PubMed Scopus (46) Google Scholar; Tajeu et al., 2015Tajeu G.S. Cherrington A.L. Andreae L. Prince C. Holt C.L. Halanych J.H. "We'll get to you when we get to you": Exploring potential contributions of health care staff behaviors to patient perceptions of discrimination and satisfaction.American Journal of Public Health. 2015; 105: 2076-2082Crossref PubMed Scopus (34) Google Scholar). Key principles include understanding sociocultural and historical context and building relationships (Principles of Community EngagementPrinciples of Community EngagementAgency for toxic substances and disease registry. National Institutes of Health, Atlanta, GA2011Google Scholar). The Patient Engagement Panel model is one specific option for patient engagement, with success tied to diverse recruitment, sustainable funding, and benefits to participants such as continuing education and compensation (Figure 1C) (Arkind et al., 2015Arkind J. Likumahuwa-Ackman S. Warren N. Dickerson K. Robbins L. Norman K. DeVoe J.E. Lessons learned from developing a patient engagement panel: An OCHIN report.Journal of the American Board of Family Medicine. 2015; 28: 632-638Crossref PubMed Scopus (15) Google Scholar). Pregnancy-focused groups should consider how to decrease the burden on participants, namely, parents of young children, such as providing childcare and meals at meetings. Potential recruits may have had traumatizing experiences with the health systems or clinics now seeking their input. Organizers should consider power dynamics when engaging patients, potentially partnering with community organizations and meeting at venues that feel welcoming and familiar to participants such as a neighborhood community center or local school (Israel et al., 1998Israel B.A. Schulz A.J. Parker E.A. Becker A.B. Review of community based research: Assessing partnership approaches to improve public health.Annual Review of Public Health. 1998; 19: 173-202Crossref PubMed Scopus (3441) Google Scholar). Health systems can also capitalize on existing patient engagement bodies. For example, regional perinatal quality collaborative groups in Michigan integrate community members and parents into quarterly collaboration and planning meetings (Michigan Department of Health and Human ServicesMichigan Department of Health and Human Services Regional Perinatal Quality Collaboratives.https://www.michigan.gov/mdhhs/0,5885,7–339-71550_96967_97028–-,00.htmlDate accessed: December 20, 2020Google Scholar). They use multiple models of engagement, including community members voting on priority areas for the committee, community members sitting on workgroups as full members, and conducting patient focus groups in the development of new programs (H. Joa, Personal Communication July 19, 2021). •Develop structures for meaningful patient participation that are well supported by the institution and implement best practices (Figure 1C).•Address power dynamics between patients and the health system by partnering with community groups or holding meetings off the hospital campus.•Query patient stakeholders on the scope of interventions, types of bias experienced, and suggestions for improvement. Implicit bias initiatives are hampered by a lack of robust measures of bias or outcomes, making efficacy challenging to assess (FitzGerald et al., 2019FitzGerald C. Martin A. Berner D. Hurst S. Interventions designed to reduce implicit prejudices and implicit stereotypes in real world contexts: A systematic review.BMC Psychology. 2019; 7: 29Crossref PubMed Scopus (107) Google Scholar). Further, evaluations often conflate knowledge retention with changes to attitudes and behaviors, which may not be accurate. In the absence of strong measures, we propose that implicit bias initiatives approach assessment as nested levels: programmatic measures, intermediate outcomes, and end outcomes (Table 2). First, programmatic measures such as participation rates and satisfaction can help to define initial implementation success. Next, intermediate outcomes can be implemented in each domain to rate whether program goals were met. For example, communication initiatives can be measured by patient satisfaction, which has been tied to perceived discrimination, stratified by race (Tajeu et al., 2015Tajeu G.S. Cherrington A.L. Andreae L. Prince C. Holt C.L. Halanych J.H. "We'll get to you when we get to you": Exploring potential contributions of health care staff behaviors to patient perceptions of discrimination and satisfaction.American Journal of Public Health. 2015; 105: 2076-2082Crossref PubMed Scopus (34) Google Scholar). Although cognitive reframing initiatives lack robust, standardized psychometric measures, one published intervention used tailored assessments to measure varied domains (Table 2) (Carnes et al., 2015Carnes M. Devine P.G. Baier Manwell L. Byars-Winston A. Fine E. Ford C.E. Sheridan J. The effect of an intervention to break the gender bias habit for faculty at one institution: a cluster randomized, controlled trial.Academic Medicine. 2015; 90: 221-230Crossref PubMed Scopus (285) Google Scholar). Finally, end-outcomes measurements can assess patient perspectives stratified by race on topics such as perceived support, perceived quality of care, and empowerment to raise concerns with a clinician. Given that data-sharing can lead to improved outcomes, results should be shared at all health system levels, including clinics, clinicians, allied health professionals, and staff (Dowding et al., 2015Dowding D. Randell R. Gardner P. Fitzpatrick G. Dykes P. Favela J. Currie L. Dashboards for improving patient care: review of the literature.International Journal of Medical Informatics. 2015; 84: 87-100Crossref PubMed Scopus (155) Google Scholar).Table 2Multilevel Outcomes Measures for Assessing Implicit Bias InterventionsLevelSample MeasuresProgrammatic outcomes•Participation rates•Participant satisfactionIntermediate outcomes•Education: Knowledge assessment•Communication: Patient satisfaction stratified by race, patient experiences of microaggressions, observed clinical encounters•Cognitive reframing (Carnes et al., 2015Carnes M. Devine P.G. Baier Manwell L. Byars-Winston A. Fine E. Ford C.E. Sheridan J. The effect of an intervention to break the gender bias habit for faculty at one institution: a cluster randomized, controlled trial.Academic Medicine. 2015; 90: 221-230Crossref PubMed Scopus (285) Google Scholar)○Awareness of personal bias○Motivation for change○Self-efficacy○Expectations that one's actions will lead to change○Listing of specific actions that reduced biasEnd outcomes•Perceived support•Perceived quality of care•Empowerment to raise concerns with a clinician•Clinical outcomes stratified by race Open table in a new tab Special consideration should be given to how implicit bias training is implemented because of its emotional salience. For interventions to be successful, leadership must communicate a commitment to bias reduction and provide resources for program implementation. Buy-in from key stakeholders, including clinicians, staff, and community groups, should be established early in the process. Buy-in can be enhanced by proactively confronting resistance to change and using interval successes to generate momentum (Baloh et al., 2018Baloh J. Zhu X. Ward M.M. Types of internal facilitation activities in hospitals implementing evidence-based interventions.Health Care Management Review. 2018; 43: 229-237Crossref PubMed Scopus (6) Google Scholar). In addition to enhanced coordination, interprofessional collaboration should be prioritized because it may lead to stigma-related attitudinal shifts (Sukhera et al., 2019aSukhera J. Miller K. Scerbo C. Milne A. Lim R. Watling C. Implicit stigma recognition and management for health professionals.Academic Psychiatry. 2019; 44: 59-63Crossref PubMed Scopus (9) Google Scholar). Interventions cannot occur in isolation: Programs should be iterative and long term (Pettker and Grobman, 2015Pettker C.M. Grobman W.A. Obstetric Safety and Quality.Obstetrics and Gynecology. 2015; 126: 196-206Crossref PubMed Scopus (38) Google Scholar). The use of formal implementation models such as “Plan–Do–Check–Act” can help to ensure continuous improvement given the limited durability of interventions studied thus far and the early stage of the literature base (Taylor et al., 2014Taylor M.J. McNicholas C. Nicolay C. Darzi A. Bell D. Reed J.E. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare.BMJ Quality Safety. 2014; 23: 290-298Crossref PubMed Scopus (706) Google Scholar). Strategies to improve sustainability include flexible program structures, eliciting feedback, and establishing a dedicated oversight group (Braithwaite et al., 2020Braithwaite J. Ludlow K. Testa L. Herkes J. Augustsson H. Lamprell G. Zurynski Y. Built to last? The sustainability of healthcare system improvements, programmes and interventions: A systematic integrative review.BMJ Open. 2020; 10: e036453Crossref PubMed Scopus (12) Google Scholar). Independent obstetrics and midwifery practices can still implement comprehensive programs, even if the scale is more limited, by ensuring that elements of each domain are addressed in some form. Partnering with regional collaboratives can also help to increase access to training. The decrease of implicit bias is essential for any campaign to combat racism in the pursuit of reduced maternal morbidity and mortality in the United States. Interventions must prioritize patient perspectives and address education, communication, and cognitive reframing. A lack of robust outcomes measures will hamper initial efforts, but this should not dampen our commitment to be better. To enhance this work, national organizations such as ACOG, Society of Maternal Fetal Medicine, and AIM can provide specific, actionable, and accessible resources for each domain. Further, funders can prioritize the piloting and evaluation of initiatives that comprehensively address all domains of implicit bias mitigation.