Unmasking obstetric care providers' empathy and color evasion in maternal health disparities: a causal attribution,...

Structural racism and discrimination underlie disparities in maternal health outcomes in the US. Provider bias, racialized clinical decision-making, and institutional structures contribute to unequal experiences and outcomes faced by Black birthing people. Using a causal attribution framework, we examined obstetric care providers' beliefs, perceptions, and knowledge regarding causes of maternal health disparities.

We conducted a mixed-methods study among 284 obstetric care providers (physicians and advanced practice providers) in Georgia from August 2023 to January 2024. A 72-item survey assessed beliefs and perceptions regarding maternal health disparities, color evasion, and empathy. Using scores for a question measuring agreement with the statement that provider behavior contributes to racial differences in maternal health care quality, we created two groups (high [≥ 5] and low [≤ 4] provider behavior attribution) and compared the distribution of survey responses between the groups. A subset of 26 survey respondents participated in seven virtual focus groups that used clinical vignettes to further explore beliefs. Integrating thematic and ideal-type analyses, this study identified emerging themes and provider typologies.

Respondents (median age 41 years; 84.5% female) were mostly physicians (82.3%) and predominantly identified as white (42.0%), Hispanic (37.4%), or Black (13.9%). Compared to respondents with low provider behavior attribution scores (N = 168), those with high scores (N = 112) were more likely to identify as Black, report greater empathy, and acknowledge personal biases influencing patient care (p<.05 for all comparisons). Color evasion scores were high across both groups. Focus groups revealed three perceived drivers of disparities: structural and systemic factors (e.g., patient blame culture); organizational constraints (e.g., care discontinuity, burnout); and interpersonal dynamics (e.g., rapport building, "two victims" in adverse events). Five provider typologies emerged: advocacy is healthcare, helpless doctor, knowledge giver, empathy as advocacy, and evasion by communication.

Findings suggest that providers may use color evasion and empathy to disguise personal bias and perpetuate racist stereotypes. The identified typologies suggest that providers use varying approaches to deflect responsibility for overcoming and addressing personal bias.